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

Treatment outcomes of permanent teeth with uncomplicated and complicated crown fractures and factors associated with pulp survival: A retrospective study

BACKGROUND

Crown fracture is the most common injury in permanent teeth. This study aimed to evaluate the treatment outcomes of permanent teeth with uncomplicated and complicated crown fractures and to investigate potential factors.

MATERIALS AND METHODS

This retrospective study included patients who experienced crown fractures in permanent teeth from 2018 to 2021 with at least 12 months of follow-up. All complicated crown fractured teeth were treated with pulpotomy, while for teeth with uncomplicated crown fractures, three treatments (restoration, indirect pulp capping, or pulpotomy) were employed. The chi-square test was used to compare the prognosis of teeth with uncomplicated and complicated crown fractures. Potential factors associated with pulp survival including gender, interval, root development, enamel infraction, mobility, concomitant luxation injury, treatment, and coronal restoration were identified via Cox regression analysis.

RESULTS

A total of 307 teeth from 220 children (average age = 9.3 ± 1.4 years; age range, 6-14 years) with a median follow-up of 23 months were included, and 82.1% of all teeth had immature roots. Complicated crown fractured teeth (93.6%, 102/109) had a significantly higher success rate compared with uncomplicated crown fractured teeth (85.4%, 169/198) (p < .05). Pulpotomy (96.9%) had the highest success rate of all treatments for uncomplicated crown fractures, followed by only restoration (85.0%) and indirect pulp capping (76.9%). The success rate of teeth that received pulpotomy was significantly higher than those treated by indirect pulp capping (p < .05). In uncomplicated crown fractures, teeth with Class II mobility were more vulnerable to failure than teeth without abnormal mobility (HR = 34.83; 95% CI, 9.59-126.56; p < .05); teeth that received pulpotomy were less prone to failure than teeth that received indirect pulp capping (HR = 13.53; 95% CI, 1.58-115.72; p < .05).

CONCLUSION

Crown fractures treated with conservative pulp treatments had a relatively highly favorable prognosis. The prognosis of uncomplicated crown fractured teeth was impacted by the severity of periodontal injury and treatment strategies. Accurate diagnosis and identification of micro-exposures are important. Dentists should take multiple risk factors into account and select optimal treatment strategies.

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.

Be Qui Vive: Unravel the Mystery of Undiagnosed for Better Prognosis

Foreign bodies may access the oral cavity by trauma or iatrogenically. Iatrogenic foreign bodies that are frequently encountered include amalgam, obturation materials, shattered equipment, needles, broken teeth, and so on. Impaction of a tooth or bone fragment in the soft tissues is one type of dental trauma. When foreign bodies are found in the teeth, it's a highly grave scenario that requires prompt diagnosis. Thorough case histories, clinical assessments, and radiographic analyses are required to draw conclusions regarding the type, dimensions, location, and challenge of the foreign body retrieval. Due to the well-known tendency of children to put foreign objects in their mouths, it is more frequently observed in them. From time to time, children get strange items lodged in their teeth, which they are afraid to tell their parents about. These foreign objects might store possible infections, which could eventually result in a painful condition. This paper discusses the presence of unusual foreign bodies-a broken pencil and tooth fragment-and their management.

How to cite this article

Kaul B, Gulbar S, Gupta A, et al. Be Qui Vive: Unravel the Mystery of Undiagnosed for Better Prognosis. Int J Clin Pediatr Dent 2024;17(4):501-509.

Reattachment of Fractured Tooth: A Comprehensive Review

Dental trauma is one of the most prevalent problems encountered in clinical practice. Traumatic injuries involving fractures of the anterior tooth are one of the most common problems among children and adolescents. There is a physical and social impact on patients' quality of life due to traumatic dental injuries (TDIs). Children and adolescents frequently present with a crown fracture that necessitates immediate intervention. Clinicians need to be aware of various treatment modalities for TDIs and have to address these injuries immediately. Due to advances in adhesive technologies, fragment reattachment is the treatment of choice when the fragment is available and well stored. The purpose of this article is to cover various techniques for reattaching fractured fragments and the most current developments in adhesive systems for this purpose.

Comparative assessment of scientific reach and utilization of the International Association of Dental Traumatology 2020 guidelines: An altmetric and citation analysis

BACKGROUND/AIM

The updated version of the International Association of Dental Traumatology (IADT) guidelines was published online in May 2020 in the form of four papers. They are extensively used in dental trauma education in textbooks, undergraduate and postgraduate programs, and clinical workshops. Hence, this study aimed to assess the impact, global scientific reach, and utilization of these guidelines through altmetric and citation analysis.

MATERIAL AND METHODS

The protocol was prepared after an expert group discussion. Dimensions database was used to derive the altmetric and citation data on April 10th, 2023. The data was extracted by using a self-designed pre-piloted form by two authors independently. The citing articles were further categorized into the type of study and the domains and subdomains of dental traumatology. The VOSviewer program was utilized to explore the correlation between the subdomains and the overlap of citations was assessed by creating a citation matrix.

RESULTS

A total of 552 citations had been collectively received by the four papers. The highest was seen for the guidelines for fracture and luxation in permanent teeth (FL), avulsion in permanent teeth (AV), general introduction (GI), and primary teeth (PT). Dental Traumatology had the maximum number of citing papers for each guideline. They were from 52 countries with English being the commonest language. Overall, the maximum number of citations had been received in narrative reviews (n = 104) and the majority of cited papers were categorized in the therapeutic domains. The most common subdomain for the papers that cited GI, FL, and AV was "treatment protocols in permanent teeth", while it was "awareness of prevention and emergency management of traumatic dental injuries" for the papers that had cited PT.

CONCLUSIONS

This analysis highlighted that the IADT 2020 guidelines are globally popular resources, which are widely used by the researchers across specialities and are intended towards clinical application.

Management of traumatic dental injuries in a hemophiliac patient: A challenge! Case report with nine years follow-up

Traumatic dental injuries (TDIs) are frequently associated with an injury pattern that requires accurate diagnosis for developing the appropriate treatment plan. When children with special healthcare needs, i.e., Hemophilia experience TDIs, managing the situation becomes a challenging task for pediatric dentists due to the requirement of a multidisciplinary approach in their care. This case report highlights the successful management of extrusive luxation injury of a young permanent tooth with an open apex in an eight-year-old male child with severe Hemophilia A. After a follow-up of nine years, the pulp showed significant healing with physiological closure of the apical foramen. The study further emphasizes that timely management of such injuries can lead to improved tooth prognosis.

The Application of Cone Beam Computed Tomography (CBCT) on the Diagnosis and Management of Maxillofacial Trauma

The assessment and management of facial trauma in an acute setting is one of the core services provided by oral and maxillofacial units in the United Kingdom. Imaging is a pre-requisite for appropriate diagnosis and treatment planning, with a combination of plain radiographs and medical-grade CT being the mainstay. However, the emergence of cone beam CT in recent years has led to its wider applications, including facial trauma assessment. It can offer multi-planar reformats and three-dimensional reconstruction at a much lower radiation dose and financial cost than conventional CT. The purpose of this review is to appraise its potential indications in all anatomical areas of maxillofacial trauma and provide our experience at a level 1 trauma centre.

Pathogenesis of non-infection related inflammatory root resorption in permanent teeth: A narrative review

BACKGROUND

The mechanism of action of root resorption in a permanent tooth can be classified as infection-related (e.g., microbial infection) or non-infection-related (e.g., sterile damage). Infection induced root resorption occurs due to bacterial invasion. Non-infection-related root resorption stimulates the immune system through a different mechanism.

OBJECTIVES

The aim of this narrative review is to describe the pathophysiologic process of non-infection-related inflammatory processes involved in root resorption of permanent teeth.

METHODS

A literature search on root resorption was conducted using Scopus (PubMed and Medline) and Google Scholar databases to highlight the pathophysiology of bone and root resorption in non-infection-related situations. The search included key words covering the relevant category. It included in vitro and in vivo studies, systematic reviews, case series, reviews, and textbooks in English. Conference proceedings, lectures and letters to the editor were excluded.

RESULTS

Three types of root resorption are related to the non-infection mechanism of action, which includes surface resorption due to either trauma or excessive orthodontic forces, external replacement resorption and external cervical resorption. The triggers are usually damage associated molecular patterns and hypoxia conditions. During this phase macrophages and clastic cells act to eliminate the damaged tissue and bone, eventually enabling root resorption and bone repair as part of wound healing.

DISCUSSION

The resorption of the root occurs during the inflammatory phase of wound healing. In this phase, damaged tissues are recognized by macrophages and neutrophiles that secrete interlaukines such as TNF-α, IL-1, IL-6, IL-8. Together with the hypoxia condition that accelarates the secretion of growth factors, the repair of the damaged perioduntiom, including damaged bone, is initiated. If the precementum and cementoblast are injured, root resorption can occur.

CONCLUSIONS

Wound healing exhibits different patterns of action that involves immune stimulation in a bio-physiological activity, that occurs in the proper sequence, with overlapping phases. Two pathologic conditions, DAMPs and hypoxia, can activate the immune cells including clastic cells, eliminating damaged tissue and bone. Under certain conditions, root resorption occurs as a side effect.

What is important to medical students' online learning of dental trauma in medical education

Traumatic dental injury (TDI), a topic not normally offered in the medical curriculum is made available through the medical school as an online learning course. Online learning provides an educational pathway for cross-disciplinary learning without any change to the existing curriculum. This research identified important key features that should be included in the design of an online course to provide a positive online learning experience for medical students. Ten important features were identified for medical educators to consider when they develop an online course to introduce dental trauma. These features are (1) prioritising information to TDI, (2) providing specific facts and information to TDI, (3) information must be easily retrieved, (4) providing career-related information, (5) promoting self-confidence, (6) promoting learning of new knowledge, (7) easy-to-understand content materials, (8) establishing a logical sequence of learning, (9) visual illustrations to complement written text and (10) promoting self-directed learning.

Holistic management of complicated crown fracture: A case series

Coronal fractures of the anterior teeth give an agonizing experience for a young individual due to the physical disfigurement, and the psychological impact that is imposed on them. One of the options for managing complicated/uncomplicated crown fractures when the tooth fragment is available, and there is no or minimal violation of the biological width is the rebonding of the fractured segment. This treatment approach is promising, providing good and long-lasting esthetics as it helps in maintaining the tooth's original anatomic form, hue, and surface texture. This article describes three case reports of successful reattachment of fractured tooth fragments. Following the root canal treatment procedures, prefabricated posts were cemented as intraradicular splint to reattach the fractured segments.

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.

Mineral Trioxide Aggregate as an Apexogenesis Agent for Complicated Crown Fractures in Young Permanent Incisor

Traumatic dental injuries are extremely common in children, and trauma to developing permanent teeth can disrupt root maturation; vital pulp therapy is an appropriate treatment for these teeth. This case report describes a 9-year-old boy who suffered dental trauma while playing football, resulting in an enamel-dentin fracture with pulp exposure in the left central incisor with an open apex (Cvek's stage 3) and an enamel-dentin fracture in the right central incisor with an open apex (Cvek's stage 3). Apexogenesis with mineral trioxide aggregate was performed to preserve the neurovascular bundle, allowing normal radicular formation in the left central incisor. During a 2-year follow-up, the tooth showed no signs and symptoms, and radiographic examinations revealed no evidence of radiolucent lesions in the periapical region. This case study provides compelling evidence that the utilization of the described agent yields significant efficacy in treating traumatic fractures accompanied by pulp exposure.

Extrusive luxation. Therapeutic procedure

Repositioning a traumatized tooth involves replacing and stabilizing it. When it is not possible, a method has been developed by an acetate splint. After few weeks, the tooth was aligned and correctly positioned.

Abstract

Repositioning a traumatized tooth involves, first, replacing and second stabilizing it. Stabilization, on the other hand, usually requires flexible splints. Occasionally the immediate replacement may be impossible being necessary to use other procedure. When complete replacement is not possible.

Is Revascularization the Treatment of Choice for Traumatized Necrotic Immature Teeth? A Systematic Review and Meta-Analysis

Regenerative endodontic treatment (RET) has been considered a reliable procedure to treat immature necrotic teeth; however, the effect of dental trauma on the prognosis of RET is questionable. This systematic review aimed to evaluate the current level of evidence for revascularization techniques (the RET) in the management of traumatized necrotic immature permanent teeth with or without periapical radiolucent areas. Four electronic databases—PubMed, Web of Science, Scopus, and Embase—were searched until November 2022. Only randomized clinical trials, cohort studies, and case-control studies with a minimum of 10 cases and 12 months of follow-ups were included. The search identified 363 preliminary results. After discarding the duplicates and screening the titles, abstracts, and full texts, 13 articles were considered eligible. The results showed that RET techniques seemed to have high survival and success rates, 93.8% and 88.3%, respectively, in the treatment of traumatized necrotic immature permanent teeth. Root maturation with RET techniques seemed to be lower in traumatized teeth. Future studies are needed to evaluate root maturation in traumatized teeth using 3-dimensional radiographic evaluations. In addition, the lack of literature on the studies comparing RET and apexification (calcium hydroxide or an MTA) in the treatment of traumatized necrotic immature teeth highlights the necessity for high-level clinical studies comparing these treatment modalities.

Knowledge, Awareness, and Practice Regarding Management of Dental Trauma in Children among Dental Practitioners: A Cross-sectional Survey

AIM

The aim of this study was to determine the current level of knowledge and understanding about dental trauma and its management in children among dental practitioners.

MATERIALS AND METHODS

The study was conducted after obtaining the ethical clearance from the Institutional Review Board (IRB). A structured questionnaire was prepared, which comprised 20 questions and was validated by dental trauma experts. The questionnaire, which covers all aspects of traumatic dental injuries (TDIs) in both primary and permanent dentition, was distributed online to 850 dental practitioners. The questionnaire was open from January 2022 to April 2022, with a 3-month time frame to complete it. The responses were collected and statistical analysis was done using SPSS software.

RESULTS

The mean age of the participants were 22-30 years. Furthermore, 515 participants were females and 263 were males. In this survey among 784 responses, 449 dentists were trained in dental trauma and 618 participants had personal experience in managing dental trauma. All other questions about knowledge and awareness of dental trauma management received fewer correct answers.

CONCLUSION

According to the present study, dental practitioners have only mild-to-moderate knowledge and awareness about dental trauma. From the latest the International Association for Dental Traumatology guidelines, dentists need to consistently update their knowledge through dental trauma conferences, workshops, trainings, and symposiums.

CLINICAL SIGNIFICANCE

This study informs us about the existing level of dental knowledge about dental trauma, which is significantly low. This will considerably boost dental practitioners' interest in TDIs. As a result, practitioners' expertise will grow, allowing them to better care for their patients.

Management of Laterally Luxated Primary Teeth: A Case Report

Lateral luxation can be defined as the traumatic displacement of a tooth in a direction other than axial. The current case report describes the use of composite resin splinting to treat laterally luxated primary maxillary central incisors which resulted in an anterior cross bit. A 5-year-old boy reported to the clinic complaining of pain and mobile front teeth that is his primary right and left central incisors were laterally luxated. After a complete clinical examination and radiographic evaluation, the teeth were repositioned and stabilized for 4 weeks by splinting the laterally luxated tooth to the adjacent teeth. Follow-up examinations revealed that the tissues had healed well and that the corresponding central permanent incisor was healthy and unaffected. This case study highlights the significance of prompt diagnosis, effective treatment, and routine follow-up of traumatized teeth because they may have an adverse effect on both dentitions and "Oral Health-Related Quality of Life". When feasible, conservative treatment should be considered because it may be more suitable in some circumstances.

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.

Oral and maxillofacial literature from Middle East: a bibliometric analysis and list of top-100 most cited articles

OBJECTIVES

The aim of this work is to perform a bibliometric analysis on Middle Eastern oral and maxillofacial surgery through years and to compare the data with previous studies. A list of the top 100 most cited articles was generated.

METHODS

A Pubmed bibliographic search for literature journals specialized in oral and maxillofacial surgery in the Middle East was performed. A graphic representation of authorship and keywords was created with VOSviewer. Mendeley and Microsoft Excel were used for tabulation and data visualization. A list of the top 100 most cited articles was created using Web of Science. Some statistical tests were performed with a 95% confidence interval, which was considered significant.

RESULTS

A total of 6,536 articles were retrieved in fifteen selected oral and maxillofacial journals. A moderate correlation between number of publications and total population (R = 0.6052), low correlation with area (R = 0.302291), and a negligible correlation with the Human Development Index (HDI) were found (R = 0.1747). A disparity can be seen in the number of publications by country, leaded by Turkey (46.30%), Israel and Iran (13.68% each). The more common studied topic was oral surgery (25.77%), maxillofacial trauma (16.13%) and oral pathology (10.25%).

CONCLUSIONS

A useful list of the top 100 most cited articles on oral and maxillofacial surgery from Middle East has been created. Middle East publications on oral and maxillofacial surgery can be considered high quality (IF = 1.879). Some issues on performing an adequate selecting of MeSH keywords were discussed.

Maintaining and Improving the Oral Health of Young Children

Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries remains greater than 40% among children 2 to 19 years of age. Although dental visits have increased in all age, race, and geographic categories in the United States, disparities continue to exist, and a significant portion of children have difficulty accessing dental care. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of disease, interventions to maintain and restore health, and the social determinants of children's oral health.

Regenerative endodontic therapy for external inflammatory lateral resorption following traumatic dental injuries: Evidence assessment of best practices

BACKGROUND

External inflammatory lateral resorption (EILR) following dental trauma is a severe complication that can lead to significant root loss and tooth extraction.

OBJECTIVE

The aim of this project was to review current evidence in the literature on regenerative endodontic therapy (RET) for EILR following traumatic injuries and assess the best treatment practices.

METHODS

Publications appearing in PubMed, from January 1, 2001 to January 9, 2022 were studied. Inclusion criteria were: (a) Publications in English; (b) Publications on RET and EILR; (c) Teeth subjected to dental trauma; and (d) Presence of intracanal bleeding and blood clots. Exclusion criteria were: (a) Conference proceedings; (b) Lectures; (c) Abstracts; and (d) Letters to editor; (e) Non-English publications.

RESULTS

355 publications were analysed. Nine met all inclusion criteria. In 10 (58.8%) teeth, triple antibiotic paste was used for an average of 26 days. Double antibiotic paste was used in 3 (17.6%) teeth for an average of 14 days. In 3 (17.6%) cases, calcium hydroxide (Ca(OH)₂ ) was used for 14 days and negative pressure irrigation was applied once on 1 (6%) tooth.

DISCUSSION

Using RET to treat EILR has some advantages compared to long term CA(OH)₂ dressing. RET requires shorter dressing time compared to CA(OH)₂ . This can significantly improve patient compliance. Additionally, in immature teeth, RET helps to arrest root resorption leading to continued root maturogenesis and revascularization. It is recommended that a meticulous follow-up should be conducted when RET is performed to assure early detection of treatment failure.

CONCLUSIONS

RET appears to be a good treatment modality producing biologic repair and improving prognosis in cases of EILR in post-traumatic tooth/pulp injuries. The key limitation of this study is that all publications included were either case reports or case series that usually tend to report successful outcome.

Complicated Crown Fracture of Permanent Incisors: A Conservative Treatment Case Report and a Narrative Review

Dental trauma may have a severe impact on the social and psychological wellbeing of a patient. Most cases of dental injuries involve anterior teeth, especially the maxillary upper incisors. Crown fractures, with or without pulp exposure, are the most common trauma in permanent dentition. There are many methods of management, in which the initial state of the pulp, the time since the injury, and the presence of an accompanying injury play a key role. This case report aimed at showing a possible conservative treatment after complicated tooth fracture that consisted of partial pulpotomy followed by adhesive reattachment of the tooth fragment using a technique based on heated resin composite. Such a specific procedure represents a conservative approach to traumatic coronal lesions, providing a suitable opportunity to maintain the tooth vitality, aesthetics, and function. Indeed, reattachment of tooth fragment using a composite/adhesive is a simple technique to achieve excellent results in terms of aesthetic and function.

Knowledge of First Aid Measures in Dental Trauma: A Survey of Teachers in the Province of Seville, Spain

The high incidence of childhood dental trauma requires childcare professionals to have basic notions of dental first aid. The aim of this study is to assess the level of knowledge and aptitude (defined as the ability to operate competently in a given activity) of early childhood, primary, and/or secondary education teachers from Seville (Spain) referred to first aid measures in dental trauma. A descriptive study was conducted. The study sample consisted of 442 teachers (334 women and 108 men) coinciding proportionately with the study target population in terms of gender distribution, type of center, and teaching level. A specifically designed questionnaire was used. Most of the participants (88.5%, n = 391) exhibited poor knowledge and aptitude, 11.5% (n = 51) showed a medium level of knowledge and aptitude, and none were categorized as having a high knowledge and aptitude. As a conclusion, teachers in the province of Seville (Spain) showed marked deficiencies in their level of knowledge and aptitude referred to the adoption of first aid measures in dental trauma among their pupils.

Spontaneous healing of complicated crown-root fractures in children: Two case reports

BACKGROUND

Complicated crown-root fracture is considered a severe dental trauma and is unlikely to heal without treatment. Usually, dentists have to remove the loose coronal fragment of the fractured tooth and treat the remaining part with multidisciplinary approaches. However, we observed spontaneous healing of fracture in two pediatric cases with a history of complicated crown-root fractures over 4 years ago.

CASE SUMMARY

In case 1, a 12-year-old boy complained of pain at tooth 11 following an accidental fall 1 d ago. Clinical examination showed a crack line on the crown of tooth 11. Cone beam computed tomography (CBCT) images of tooth 11 showed signs of hard tissue deposition between the fractured fragments. The patient recalled that tooth 11 had struck the floor 1 year ago without seeking any other treatment. In case 2, a 10-year-old girl fell down 1 d ago and wanted to have her teeth examined. Clinical examination showed a fracture line on the crown of tooth 21. CBCT images of tooth 21 also showed signs of hard tissue deposition between the fractured fragments. She also had a history of dental trauma 1 year ago and her tooth 11 received dental treatment by another dentist. According to her periapical radiograph at that time, tooth 21 was fractured 1 year ago and the fracture was overlooked by her dentist. Both of these two cases showed spontaneous healing of complicated crown-root fractures. After over 4 years of follow-up, both fractured teeth showed no signs of abnormality.

CONCLUSION

These findings may provide new insights and perspectives on the management and treatment of crown-root fractures in children.

An Alternative Approach Using Circummandibular Wiring for Treatment of Dentoalveolar Fractures in Children: A Case Report

The prevalence of dentoalveolar injuries in children is approximately 25%, with falls from own height being one of the main etiologies. Diagnosis is based on the clinical evaluation associated with complementary imaging tests. The treatment of choice depends on the type of damage and structure affected. For alveolar process fractures, closed reduction and semi-rigid dental splinting for 4 to 6 weeks is generally satisfactory. However, some cases, such as severe segmental fractures, require open treatment to ensure adequate reduction and stabilization of the displaced alveolar segment, which is usually achieved by titanium miniplates and screws. Nevertheless, there are situations where this type of fixation is not possible, requiring alternative methods. Therefore, this article describes a surgical technique performed by open reduction, associating semi-rigid dental splint and circummandibular wiring in pediatric patient diagnosed with dentoalveolar fracture through clinical examination (with bone fracture displacement) and tomography. The technique promoted a good prognostic to the patient, proving to be a viable alternative for treating dentoalveolar fractures.

Management of Periapical Lesion Associated With Root Fracture in the Elderly: A Case Report

The early detection and management of root fractures pose a challenge to dentists. There are two treatment options in such cases: conservative and endodontic or surgical. Follow-up of such cases involves the continual evaluation of the tissue repair process and the possible occurrence of undesirable events, such as periapical lesions, pulp calcification, and internal or external resorption. This case report describes the finding of a periapex with relatively extensive bone rarefaction resulting from a root fracture in a 64-year-old male who presented with gingival hyperplasia in the right maxillary lateral incisor region sensitivity at the touch of the exploratory probe and mild bleeding with exudate. In this case, the early diagnosis of root fracture enabled the choice of the best therapeutic option with a satisfactory outcome.

Lateral luxation: Is root resorption an unavoidable complication?

Lateral luxation is defined as a traumatic displacement of a tooth in any direction other than axially. A laterally luxated tooth is often immobile because of its bony lock. It produces a high metallic sound during percussion. Pulp sensibility testing is likely to be negative during the initial follow‐up. However, the tooth should be monitored until a definitive pulp diagnosis is made. Treatment includes local anesthesia, suturing soft tissue injuries, manual repositioning of the luxated tooth, and stabilization with a flexible splint for 4 weeks. Given the risk of pulp necrosis following lateral luxation, particularly in teeth with radiographically closed apices and severe displacement, an immediate (prophylactic) root canal treatment is recommended. The objective of this work was to report and discuss the management of a case of lateral luxation involving a permanent tooth treated by reduction, followed by contention with 0.4 steel wire and composite resin, and endodontic treatment, and which was complicated by root resorption 3 months later. We also highlighted the possible complications following lateral luxation, especially root resorption.

The key clinical message of this case report is to detail the management of lateral luxation and to highlight the importance of clinical and radiological follow‐up in order to detect the possible complications, particularly root resorption.

Effect of dental trauma management resources on dental practitioners' confidence and knowledge: A pilot cross-sectional study

BACKGROUND/AIM

The knowledge of standardized care guidelines is critical to the confidence of practitioners in managing dental trauma. Therefore, the aim of this study was to assess the awareness, use and impact of the International Association of Dental Traumatology guidelines, and the online Dental Trauma Guide on general dental practitioners' self-reported confidence and knowledge in managing traumatic dental injuries in the primary and permanent dentitions.

MATERIALS AND METHODS

A cross-sectional, pre-piloted, 27-item self-administered questionnaire survey was distributed electronically to general dental practitioners' working within five member states of the Gulf Cooperation Council countries (Kingdom of Bahrain, Kingdom of Saudi Arabia, Kuwait, Oman, and Qatar) between September and December 2020. Data were collected and analysed using descriptive statistics and Wilcoxon Signed Rank test analysis for relevant comparisons.

RESULTS

A total of 294 respondents completed the survey, with the majority being from the Kingdom of Saudi Arabia (47.4%) and Qatar (27.3%). A lack of evidence-based knowledge in managing traumatic dental injuries was evident among more than half of the respondents. Respondents who were cognizant of the recent International Association of Dental Traumatology guidelines (2020) and those who use the Dental Trauma Guide routinely demonstrated a higher self-reported confidence level in managing both simple and complex primary dentition trauma, as well as simple traumatic dental injuries in the permanent dentition (p < .05).

CONCLUSION

This survey highlights critical deficiencies in the knowledge of a large number of the respondents in the management of dental trauma which is likely to cause irreversible long-term patient effects.

Comparative Evaluation of Corneal Storage Medias Used as Tooth Avulsion Medias in Maintaining the Viability of Periodontal Ligament Cells Using the Cell Counting Kit-8 Assay

Purpose

The prime factor in determining the success of reimplantation of an avulsed tooth is the maintenance of the viability of periodontal ligament fibroblast cells (PDFC). This study aims to evaluate and compare Mc Carey Kaufman media (MK), Cornisol, Dulbecco’s Modified Eagles Medium (DMEM), Hanks Balanced Salt Solution (HBSS) and distilled water in preserving the viability of the PDFC using the Cell Counting Kit-8 assay (CCK-8).

Methods

Cryopreserved PDFC were suspended in DMEM and incubated in CO₂ incubator at 370C with 95% humidity and 5% CO₂ for attachment. Once cells attained 80% confluence, they were trypsinised and passed into T-25 culture flasks to expand the culture population. Cells from passage 5 were pooled for experimentation. Trypan blue exclusion test was performed before each experiment to measure cell viability and batches showing more than 95% viability were used in the experiment. The viable PDFC with 1×105 were seeded in 96 well plates and incubated in CO₂ incubator at 370C, 95% humidity and 5% CO₂ for 24 hours to allow cell attachment. A 100µL of the experimental media were added in the wells and the cells were exposed for 1, 24 and 48 hours respectively. The viability was determined using the CCK-8. Experiment was performed in triplicates and data was subjected to statistical analysis.

Results

Statistical analysis was performed using repeated measure ANOVA, ANOVA, and post-hoc Bonferroni test with the significance level p<0.05. The values are as follows: MK (1.3146 ±0.0588, 1.9012±0.0511, 2.0723±0.1211) > Cornisol (1.2399±0.0548, 1.9596±0.0652, 1.9592±0.1361) >DMEM (1.1914±0.0691, 1.8479±0.0116, 2.0718±0.0795) > HBSS (0.3665±0.0814, 0.0184±0.0010, 0.0248±0.0042) >distilled water (0.0122±0.0033, 0.0225±0.0085, 0.0104±0.0008) at 1 hour, 24 hours and 48 hours respectively. MK >Cornisol>DMEM>HBSS>distilled water.

Conclusion

It can be concluded that the corneal preservation solutions showed promising results in preserving periodontal ligament cell viability for extended time periods.

Making sense of sensibility: part 2

To reach an accurate endodontic diagnosis, it is important for clinicians to understand how to undertake pulpal sensibility tests correctly, how to interpret their results and how to understand their limitations. Part one of this series defined different terms relevant to pulp testing and detailed the diagnostic uses and diagnostic accuracy of pulp testing methods. This section describes clinical techniques for commonly used pulp tests and highlights their limitations and correct interpretation of their results. Applying these principles and techniques will enable accurate endodontic diagnosis in different clinical scenarios.

Knowledge and Awareness of School Teachers Regarding Emergency Management of Tooth Avulsion in the Kingdom of Saudi Arabia: A Cross-Sectional Study

Aim:

This study aimed to assess the general knowledge and awareness of school teachers regarding the first aid emergency dental management of tooth avulsion in the kingdom of Saudi Arabia.

Materials and Methods:

A self-administered, anonymous, close-ended structured questionnaire was given to school teachers in Saudi Arabia. It included information regarding gender, knowledge, and awareness [three parts: basic demographic characteristics focusing on the gender (part one), questions regarding knowledge of school teachers toward emergency management of tooth avulsion (part two), and questions regarding awareness of school teachers toward emergency management of tooth avulsion (part three)].

Results:

A total of 615 school teachers (58% males and 42% females) completed the questionnaire. Approximately 54.3% of the school teachers preferred to immediately refer the child to the dentist if trauma affects permanent teeth (p < 0.05), and only 2.1% opined regarding reposition of the tooth in a normal position. Another 22.9% responded that they would scrub the tooth to clean the dirt and rinse with water, while 19.7% reported that they would keep the tooth in a wet handkerchief until they reach the dentist.

Conclusion:

The knowledge and awareness of schoolteachers regarding the management of avulsed teeth are insufficient; thus, education programs on traumatic dental injuries are essential.

Parental and training coaches' knowledge and attitude towards dental trauma management of children

BACKGROUND

The aim of this study was to evaluate parental and training coaches' knowledge and attitude towards traumatic dental injuries (TDIs) among children.

MATERIAL AND METHODS

A 31-item questionnaire was distributed to the parents and training coaches attending local sporting clubs in Brisbane region, Australia. The questionnaire consisted of five parts (i) demographic and professional information; (ii) TDIs in the primary dentition; (iii) fractures and subluxation of permanent teeth (iv) avulsion of permanent teeth, and (v) information and knowledge related to the management of traumatized teeth. The jamovi (Version 1.6.3) and GraphPad Prism were used for data analysis.

RESULTS

A total of 233 participants were surveyed, 211 parents and 22 coaches. Of all types of injuries, parental knowledge of managing avulsion to permanent teeth was poorest (9.5%), followed by management of injuries of primary teeth (17.5%) and management of fractures or subluxation of permanent teeth (29.4%). Parents in health care occupations had higher satisfaction on self-knowledge in managing TDIs however there was no significant difference in knowledge levels between health care personnel and other professions (P = 0.128). There was a discrepancy between the lack of knowledge and willingness to further self-educate with online platforms being the preferred medium.

CONCLUSION

The study showed a gap in parents' and training coaches' knowledge regarding the management of TDIs among children.

Observation periods before tooth movement in orthodontic patients who have experienced mild-to-moderate dental trauma: a scoping review of current evidence

BACKGROUND

Guidelines for orthodontic patients that have experienced mild-to-moderate dental trauma recommend an observation period before beginning or resuming tooth movement, but they appear to be based on limited evidence.

OBJECTIVES

This scoping review examines available research on recommended observation periods before beginning or resuming tooth movement for orthodontic patients that have experienced mild-to-moderate dental trauma. The extent of research, methodologies used, outcomes reported, and justification for recommended observation periods were reviewed to identify any gaps in current knowledge.

DESIGN

Online databases were searched to identify papers published from 1950 to September 2021. Two publications, one from Sweden and one from Israel, reported dental outcomes of tooth movement with versus without observation periods for orthodontic patients that had experienced trauma. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-1) tool.

RESULTS

One article was published in 1982, and the other in 1991. Both were observational retrospective cross-sectional studies of orthodontic patients with a history of mild-to-moderate trauma to permanent teeth (uncomplicated crown fracture, concussion, subluxation, luxation), ranging in age from 7 to 16 years. The studies listed a variety of outcomes, including clinical exams, electric pulp testing, and analysis of periapical or panoramic radiographs for signs of root resorption.

CONCLUSIONS

The identified articles lack sufficient evidence to determine an appropriate observation period after mild-to-moderate trauma before beginning or resuming orthodontic treatment. High-quality research is needed to better define appropriate observation periods before beginning or continuing orthodontic treatment for mildly to moderately traumatized teeth.

Regenerative Endodontic Procedures in Immature Permanent Teeth With Dental Trauma: Current Approaches and Challenges

After dental trauma to immature permanent teeth (IPT), there can be pulpitis, necrotic, and periapical periodontitis, which will halt further root development. Traditional endodontic root canal treatments and apexification cannot revitalize the necrotic pulp to revitalize the tooth to promote further root development. As a consequence, IPT with thin dentinal walls can be prone to fracture and if a fracture occurs, the patient will likely suffer the loss of the tooth. In an attempt to save IPT, there has been a growing interest among dentists to use regenerative endodontic procedures (REPs) to revitalize a replace dental pulp to continue root development and strengthen the dentinal walls to help prevent a subsequent loss of the tooth. However, the effectiveness of REPs and the precise methods to successfully accomplish REPs are controversial. Therefore, the objective of this review is to compare the different approaches to REPs in case reports by highlighting their advantages and limitations.

IADT 2020 Guidelines: What should the dental professional know?

Traumatic dental injuries are a common occurrence among children. Effective acute and long-term management of traumatic dental injuries can improve patient outcomes, especially in the paediatric patient. It is important that all dental professionals follow up-to-date, evidence-based guidance when treating patients. This article aims to highlight the main changes in the 2020 International Association of Dental Traumatology (IADT) Guidelines for Evaluation and Management of Traumatic Dental Injuries, to ensure that all dental professionals are fully aware of current guidelines and are managing patients appropriately.

LeFort Fractures

Consultations for management of facial fractures in the emergency setting are not uncommon for the oral maxillofacial surgeon, otolaryngologist, and/or plastic surgeon. This necessitates a knowledge foundation and working understanding of the evaluation, assessment, and timely management. Here, we will focus on the workup and management of LeFort fractures.

Management of Pulp Canal Obliteration-Systematic Review of Case Reports

Background and Objectives: This systematic review aimed to assess the literature focusing on the clinical management of traumatized teeth with Pulp Canal Obliteration (PCO) and propose an updated clinical decision-making algorithm. The present review follows the PRISMA guidelines and was registered on PROSPERO database (CRD42020200656). Materials and Methods: An electronic search strategy was performed in Pubmed, EBSCOhost and LILACS from inception to March 2021. Only anterior permanent teeth with PCO due to dental trauma were included. Regarding clinical approaches, only teeth managed with a “watchful waiting” approach, tooth bleaching or root canal treatment (RCT) were included. Quality assessment was performed using the JBI Critical Appraisal Tool for Case Reports. Results: Twenty case reports were selected, resulting in a total of 27 patients. The number of traumatized teeth diagnosed with PCO was 33. The “watchful waiting” approach was the most implemented clinical strategy. Discolored non-symptomatic PCO teeth were mostly managed with external bleaching. The prevalence of pulp necrosis (PN) was 36.4%. For teeth diagnosed with PN, non-surgical RCT was performed in 10 teeth and surgical RCT in one tooth. Guided endodontic technique was performed in six of those teeth. Conclusions: For discolored non-symptomatic PCO teeth, external bleaching is advocated and the RCT approach should not be implemented as a preventive intervention strategy. Symptomatic PCO teeth should follow regular endodontic treatment pathways. Clinical approach of teeth with PCO should follow a decision-making algorithm incorporating clinical and radiographic signs and patient-reported symptoms.

Decision-Making and Management of Immature Permanent Teeth with Crown Fractures in Small Animals-A Review

Immature permanent teeth with crown fractures present a unique challenge in human and animal patients. Immature permanent teeth have not yet developed completely, often presenting with thin dentin walls, incomplete apical formation, and increased crown-to-root ratios. Loss of pulp function at this stage has devastating long-term implications for these teeth. Ideally, attempts should be made to preserve pulp vitality in immature permanent teeth to allow for continued dental development. The range of treatment options for vital teeth includes odontoplasty with bonding and sealing +/- restoration, indirect pulp capping, and direct pulp capping/vital pulp therapy. These treatments have long been established in human and veterinary medicine, and cases have been reported in dogs and cats. Apexification using calcium hydroxide is a well-established treatment for nonvital immature teeth. The advent of mineral trioxide aggregate and other bioceramic materials for use in vital pulp therapy and apexification has reduced treatment sessions and improved outcomes. Recent developments in the field of regenerative endodontic therapy further expand treatment options and provide the possibility for continued development of a formerly nonvital tooth. Selecting the appropriate treatment based on the severity of tooth fracture and status of pulp vitality can avoid a lifetime of poor structure and function for the affected tooth. This article provides multiple step-by-step protocols for the management of immature permanent teeth with crown fractures in small animals.

The Influence of Dental Trauma Education on Undergraduate Students at Ajman University, United Arab Emirates: An Interventional Study

BACKGROUND AND OBJECTIVES

The main objective of this study was to assess the impact of a lecture on dental trauma on the knowledge of undergraduate dental students at Ajman University in the United Arab Emirates (UAE).

METHODS

Fourth-year dental students were asked to attend a lecture on dental trauma and then respond to an online questionnaire containing 10 close-ended questions related to their approach to managing dental trauma cases and tooth avulsion before (T0) and directly after (T1) the lecture. They were given 5 min for filling the questionnaire either time. McNemars test was used to compare the accuracy of their answers based on the correct or incorrect response for each question. The level of significance was set at p < 0.05.

RESULTS

The questionnaire was sent to 164 students, out of which 157 responded, giving a response rate of 95.7%. After receiving the educational intervention, the students showed a significant improvement in their knowledge on managing permanent tooth avulsion, especially regarding the handling of an avulsed tooth before replantation, extra-alveolar time, and media used for the storage and transportation of avulsed teeth (< 0.001).

CONCLUSION

The study reveals that the lecture on dental trauma had an excellent outcome on the knowledge of the students. Therefore, it is essential to emphasize the importance of this information among undergraduate dental students in order to save teeth exposed to trauma and to reduce the social burden of such cases. This study contributes to better understanding of the effect of dental trauma education on undergraduate dental students' knowledge of the subject.

The Role of Information in Dental Traumatology in Patients during Developmental Age: A Cognitive Investigation

Objectives  The gestation period involves a series of changes in all maternal organs and systems, due to hormonal fluctuations that also affect the oral cavity, leading to possible development of diseases such as gingivitis, oral pregnancy tumor, or periodontitis. Over the years, the positive correlation between poor oral health and adverse outcomes in pregnancy, such as fetal changes, low birth weight, preterm birth, or preeclampsia, has also been highlighted. The aim of this study is to analyze and understand the levels of knowledge and information of pregnant women about the possible repercussions that they may have on the oral cavity, caused by hormonal alterations.

Materials and Methods  A questionnaire of 17 multiple choice questions was formulated and published online from 01/02/2020 to 31/08/2020, aimed at pregnant women and new mothers. The Google Forms platform was used to collect the data that were then statistically analyzed by creating crosstabs with multiple dependency variables.

Results  The study cohort was represented by 1,191 women, whose responses first showed that about half were unaware of the predisposition to develop infections and periodontal problems during the gestation period. The same noticed bleeding and gum swelling during brushing and despite this, only 21% visited their dentist to resolve the situation. Furthermore, 88.2% of all women did not know that problems in the oral cavity can lead to adverse pregnancy outcomes.

Conclusion  Primary prevention is essential and must be implemented with the collaboration of the various professional figures who follow the woman during gestation.

[Application of the dental trauma guide of the international association of dental traumatology in a group of paraguayan dentists]

Objective

To evaluate the application of the dental trauma guide according to the International Association of Dental Traumatology in a group of Paraguayan dentists from April to May 2021. The was a descriptive, cross-sectional, observational study. A group of Paraguayan dentists with internet access accepted to participate in the study. The measurement instrument was a closed questionnaire from Google Forms, distributed by instant messaging (WhatsApp) from January to April 2021. Based on the Guidelines for the Evaluation and Management of Traumatic Dental Injuries by the International Association of Dental Traumatology (IADT), the questionnaire includes 20 questions on the assessment of clinical and radiographic signs, determination of treatment variables, differentiation of the type of treatment, biological consequences of trauma, materials and splint time, and postoperative indications and medication.

Results

230 dentists participated; the mean age was 33 (SD = 6.4) years, 70.43% were women, 30.87% were general dentists, and 70.87% were practicing exclusively in private practice. 68.70% responded that they were familiar with the management and treatment of dentoalveolar trauma, while 70.87% had not heard or read about the IADT dental trauma guide. Regarding the level of knowledge, 60.00% scored an average mark.

Conclusion

Most of the dentists surveyed had moderate knowledge regarding the evaluation and management of traumatic dental injuries.

What Are Possible Contributors to Associated Dental Injury in Mandibular Fractures?

PURPOSE

Among previous reports on dental injuries associated with mandibular fractures, there are few investigating the conditions under which dental injuries commonly occur. The aim of this study was to determine specific characteristics of mandibular fractures accompanied by dental injuries.

METHODS

This retrospective cohort study included dentate patients with mandibular fractures treated at a tertiary trauma center between 2011 and 2019. The data were analyzed according to 2 outcome variables: patients with additional dental injuries and patients without. The predictor variables were patient age, sex, accident mechanism, number and location of mandibular fractures, and presence of submental lacerations. Odds ratios for the risk factors for dental injury were calculated in conjunction with descriptive statistics. Binary logistic regression analysis was also performed to identify the factors associated with dental injuries as dependent variables.

RESULTS

Of 252 patients who had only mandibular fractures, 95 (37.7%) had associated dental injuries. In the group with dental injuries, 55.8% of mandibular fractures were caused by a fall (P = .003). Condyle fractures (77.9%) with dislocation (67.6%) and bilateral involvement (41.9%) were more common than in the group without dental injuries (P < .001). In patients with dental injuries, the incidence of 3 or more fractures (29.5%) was significantly higher than in the group without dental injuries. Dental injuries were more likely to occur in patients with concomitant submental lacerations (confidence interval (CI) 1.135-4.983, P = .02), and the risk of dental injury was significantly lower in the presence of angle fractures (CI 0.113-0.999, P = .045).

CONCLUSIONS

A frontal impact involving the anterior part of the mandible is often associated with condyle and multiple mandibular fractures. This seems to be the typical mechanism for concomitant dental injuries. Submental laceration can be considered a prime sign of associated dental injuries.

Biomechanical Analysis of a Custom-Made Mouthguard Reinforced With Different Elastic Modulus Laminates During a Simulated Maxillofacial Trauma

Background/Aims

There is a lack of data regarding the influence of different laminates for mouthguard reinforcement in the mechanical response during an impact in the orofacial region. The aim of this study was to verify the influence of the laminate framework on the stresses and strains of the anterior teeth and displacement of ethylene-vinyl acetate (EVA) custom-made mouthguards during a simulated impact. The null hypotheses was that the different laminates reinforcement would present the similar effect in maxillary structures, regardless the elastic modulus.

Methods

A finite element model of human maxillary central incisors with an antagonist contact was used. A linear quasi-static analysis was used to simulate the force exerted during an impact. A total of 5 different layers were simulated inside the mouthguard at the labial portion according to the Elastic Modulus 1 MPa (Extremely flexible), 9 GPa (Low modulus reinforcement), 18 GPa (Without reinforcement), 50 GPa (Flexible alloy), 100 GPa (Titanium alloy) and 200 GPa (Hard material). The results were evaluated by means of Maximum Principal Stress (in the tooth and bone), Microstrain (periodontal ligament) and Displacement (mouthguard) criteria.

Results

The elastic modulus of the material inside the MG influenced the stress distribution on the enamel buccal face. However, it did not affect the bone tissue stress, periodontal ligament strain or root dentin tissue stress. Conclusion: The use of reinforcement inside the custom-made mouthguard can modify the stress generated in the enamel buccal surface without improvement to the root dentin, periodontal ligament or bone tissue.

A three-dimensional finite element analysis of stress distribution in maxillary central incisor with a horizontal mid root fracture after various management protocols

Context

The incidence of root fractures is about 1.2%-7% in permanent teeth and horizontal mid root fractures are most common in maxillary anteriors.

Aims

This study aims to evaluate the stress distribution in a maxillary central incisor with mid root fracture after various management protocols using three-dimensional finite element (FE) analysis.

Materials and Methods

Four three dimensional FE models were constructed: Model 1-Normal tooth, Model 2-tooth with horizontal mid root fracture, Model 3-tooth with horizontal mid root fracture, coronal fragment filled with Biodentine, and access cavity sealed with composite resin cement and apical fragment left untreated and Model 4-tooth with horizontal mid root fracture restored with intraradicular fiber post as a splint and access cavity sealed with composite resin cement. The properties of materials were assigned and a force of 100 N was applied at 45° angle to the longitudinal axis of the tooth onto the palatal surface incisal to the cingulum.

Statistical Analysis

Von-Mises stress along the length of the root analyzed and compared.

Results

The maximum stress distribution was observed at the palatal end of the coronal radicular fragment in both without treatment and with biodentine treatment. The stress distribution was concentrated more at the junction of the splinted area in the intraradicular fiber post splinted model.

Conclusions

The model with intraradicular fiber post as a splint exhibited more stress concentration at the splinted area due to bending forces. These stresses may adversely affect the healing around the fracture site and affect the longevity.

Accidental avulsion of a recently traumatised maxillary anterior tooth during rubber dam application

Avulsion injuries are usually seen in the anterior maxillary teeth as a result of trauma. Avulsion as an endodontic mishap is extremely rare. This report highlights an unusual instance of exarticulation of a recently traumatised maxillary central incisor tooth when the rubber dam was applied during a routine non-surgical endodontic procedure. The tooth was immediately repositioned and stabilised with wire composite splint. Endodontic treatment was initiated after rubber dam isolation with a modified technique. Calcium hydroxide was used as intracanal medicament dressing, and obturation was done after 2 weeks. The treatment was successful with uneventful periodontal healing at 24-month follow-up. The presence of well-demarcated periodontal ligament space and absence of any resorptive area on the radiograph could be defined as a successful outcome for the present case.

Minimal intervention treatment of crown-root fracture in a mature permanent tooth by MTA pulpotomy and Fragment Reattachment: A Case Report

Treatment of crown-root fracture can be complicated, time-consuming and expensive. This paper presents a treatment approach that minimises intra-operatory intervention and preserves the biologic tissue. A 15-year-old boy reported for treatment of an oblique crown fracture in the left permanent maxillary central incisor (#21, Fédération Dentaire Internationale) with mature root apices. The treatment presented an endodontic, periodontal and restorative challenge as the crown fracture exposed the pulp and extended subgingivally. The patient also had accompanying generalised enamel hypoplasia due to dental fluorosis (grade 3 Deans Fluorosis index), making the aesthetic rehabilitation difficult. The case was managed by preserving the vital pulp by MTA pulpotomy, followed by the adhesive bonding of autogenous crown fragment. A three-year follow-up revealed healthy vital pulp tissue and retained bonded fragment with acceptable aesthetics and periodontal health.