R EFER EN C E M A N U A L V 37 / NO 6 15/16

Guidelines for the Management of Traumatic Dental

Injuries: 1. Fractures and Luxations of Permanent Teeth
Originating Group
International Association of Dental Traumatology

Endorsed by the American Academy of Pediatric Dentistry

2013

Anthony j. DiAngelis*1 • Jens 0. Andreasen*2 • Kurt A. Ebeleseder*3 • David J. Kenny*4 • Martin Trope*5 • Asgeir Sigurdsson*6 • Lars Andersson7
Cecilia Bourguignon8 • Marie Therese Flores9 • Morris Lamar Hicks10 • Antonio R. Lenzi11 • Barbro Malmgren12 ■ Alex J. Moule13 • Yango Pohl14 •
Mitsuhiro Tsukiboshi15

Abstract: T ra u m a tic d e n ta l in ju rie s (TDIs) o f p e rm a n e n t te e th o c c u r fr e q u e n tly in c h ild re n a n d y o u n g a d u lts . C ro w n fra c tu re s a n d lu x a tio n s

a re th e m o s t c o m m o n ly o c c u rrin g o f a ll d e n ta l in ju rie s. P ro p e r d ia g n osis, tr e a tm e n t p la n n in g a n d fo llo w u p a re im p o r ta n t f o r im p ro v in g
a fa v o ra b le o u tc o m e . G u id e lin e s s h o u ld assist d e n tis ts a n d p a tie n ts in d e c is io n m a k in g a n d f o r p r o v id in g th e b e s t care e ffe c tiv e ly a n d
e ffic ie n tly . The In te rn a tio n a l A s s o c ia tio n o f D e n ta l T ra u m a to lo g y (IAD T) has d e v e lo p e d a consensus s ta te m e n t a fte r a re v ie w o f th e d e n ta l
lite r a tu r e a n d g ro u p discussions. E xp e rie n ce d re se a rch e rs a n d c lin ic ia n s fr o m va rio u s s p e c ia ltie s w e re in c lu d e d in th e g ro u p . In cases w h e re
th e d a ta d id n o t a p p e a r conclusive, re c o m m e n d a tio n s w ere b a s e d o n th e consensus o p in io n o f th e IA D T b o a rd m e m b e rs . The g u id e lin e s
re p re s e n t th e b e s t c u rre n t e vid e n ce b a se d on lite ra tu re se a rch and p ro fe s s io n a l o p in io n . The p r im a r y goal o f th e se g u id e lin e s is to
d e lin e a te a n a p p ro a c h f o r th e im m e d ia te o r u rg e n t care o f TDIs. In th is fir s t a rtic le , th e IA D T G u id e lin e s f o r m a n a g e m e n t o f fra c tu re s a n d
lu x a tio n s o f p e rm a n e n t te e th w ill b e p re s e n te d . (D e n ta l T ra u m a to lo g y 2 0 1 2 ;2 8 :2 -1 2 ; d o i: 1 0 .llli/j.1 6 0 0 -9 6 5 7 .2 0 1 l.0 l1 0 3 .x) A c c e p te d ja n u a r y 7, 2012.

KEYWORDS: CONSENSUS, FRACTURE, LUXATION, REVIEW, TRAUM A, TOOTH

1Department of Dentistry, Hennepin County Medical Center and Uni­
versity of Minnesota School of Dentistry, Minneapolis, MN, USA; 2Center
of Rare Oral Diseases, Department of Oral and Maxillofacial Surgery,
Copenhagen University Hospital, Rigshopitalet, Denmark; departm ent of
Conservative Dentistry, Medical University Graz, Graz, Austria; 4Hospital
for Sick Children and University of Toronto, Toronto, Canada;
departm ent of Endodontics, School of Dentistry, University of Pennsyl­
vania, Philadelphia, PA, USA; departm ent of Endodontics, UNC School
of Dentistry, Chapel Hill, NC, USA; departm ent of Surgical Sciences,
Faculty of Dentistry, Health Sciences Center Kuwait University, Kuwait
City, Kuwait; sPrivate Practice, Paris, France; 9Pediatric Dentistry, Faculty
of Dentistry, Universidad de Valparaiso, Valparaiso, Chile; wDepartment
of Endodontics, University of Maryland School of Dentistry, Baltimore,
MD, USA; u Private Practice, Rio de Janeiro, Brazil; 12Department of
Clinical Sciences Intervention and Technology, Division of Pediatrics,
Karolinska University Hospital, Stockholm, Sweden; 13Private Practice,
University of Queensland, Brisbane, Australia; 14Department of Oral
Surgery, University of Bonn, Bonn, Germany; 'Private Practice, Amagun,
Aichi, Japan.
Correspondence to Anthony J DiAngelis. DMD, MPH, Hennepin County
Medical Center, 701 Park Avenue South .Minneapolis, MNggqig, USA.
Tel.: 612 Spy -6t7y
Fax: 612-gog-gyig
e-mail: anthony.diangelis@hcmed.org
* Members of the Task Group.
W h e n e v e r r e fe r r in g t o IA D T G u id e li n e s , t h e o r i g i n a l a r t i c l e ,
(D e n t T ra u m a to l 2 0 1 2 ;2 8 :2 -1 2 ) s h o u ld a lw a y s
re fe re n c e .
Traumatic dental injuries (TDIs) occur with great
frequency in preschool, school-age children, and young
adults comprising 5% of all injuries for which people
seek treatment (1, 2). A 12-year review of the literature
reports that 25% of all school children experience dental
trauma and 33% of adults have experienced trauma to
the permanent dentition, with the majority of injuries
occurring before age nineteen (3). Luxation injuries are
the most common TDIs in the primary dentition,
whereas crown fractures are more commonly reported
for the permanent dentition (1, 4, 5) TDIs present a
challenge to clinicians worldwide. Consequently, proper
diagnosis, treatment planning and follow up are critical
to assure a favorable outcome.
Guidelines, among other things, should assist dentists,
other healthcare professionals, and patients in decision
making. Also, they should be credible, readily under­
standable. and practical with the aim of delivering
appropriate care as effectively and efficiently as possible.
The following guidelines by the International Associ­
ation of Dental Traumatology (IADT) represent an
updated set of guidelines based on the original guidelines
published in 2007 (6-8). The update was accomplished
by doing a review of the current dental literature using
EMBASE. MEDLINE, and PUBMED searches from
1996 to 2011 as well as a search of the journal of Dental
Traumatology from 2000 to 2011. Search words included
tooth fractures, root fractures, tooth luxation, lateral
be used as
luxation and permanent teeth, intruded permanent teeth,
and luxated permanent teeth.

Copyright © 2012, International Association of Dental Traumatology, w w w .ia d t-d e n ta ltra u m a .o rg .

Reprinted with permission of the International Association of Dental Traumatology (IADT). D e n ta l T ra u m a to lo g y 2012;28:2-12; d o i: I0.l111/j.1600-9657.2011.01103.x.
A va ila b le a t h ttp ://o n lin e lib ra ry .w ile y .e o m /d o i/1 0 .in i/J .l6 0 0 -9 6 5 7 .2 0 1 l.D H 0 3 .x /fu ll.

322 ENDORSEMENTS

The primary goal of these guidelines is to delineate an
approach for the immediate or urgent care of TDIs. It is
understood that subsequent treatment may require
secondary and tertiary interventions involving specialist
consultations, services, and/or materials methods not
always available to the primary treating clinician.
The IADT published its first set of guidelines in 2001
and updated them in 2007 (6-13). As with the previous
guidelines, the working group included experienced
investigators and clinicians from various dental specialties
and general practice. This revision represents the best
evidence based on the available literature and expert
professional judgment. In cases where the data did not
appear conclusive, recommendations are based on the
consensus opinion of the working group followed by
review by the members of the IADT Board of Directors. It
is understood that guidelines are to be applied with
evaluation of the specific clinical circumstances, clinicians’
judgment, and patients’ characteristics, including but not
limited to compliance, finances, and understanding of the
immediate and long-term outcomes of treatment alterna­
tives versus non-treatment. The IADT cannot and does
not guarantee favorable outcomes from strict adherence
to the Guidelines, but believe that their application can
maximize the chances of a favorable outcome.
Guidelines undergo periodic updates. These 2012
Guidelines in this journal will appear in three parts:
Part I: Fractures and luxations of permanent teeth
Part II: Avulsion of permanent teeth
Part III: Injuries in the primary dentition
Guidelines offer recommendations for diagnosis and
treatment of specific TDIs; however, they do not provide
the comprehensive nor detailed information found in
textbooks, the scientific literature, and, most recently, the
Dental Trauma Guide (DTG) that can be accessed on
http://www.dentaltraumaguide.org. Additionally, the
DTG, also available on the IADT’s web page http://
www.iadt-dentaltrauma.org, provides a visual and ani­
mated documentation of treatment procedures as well as
estimations of prognosis for the various TDIs.
General recommendations/considerations
Clinical examination
Detailed description of protocols, methods, and docu­
mentation for clinical assessment of TDIs can be found
in current textbooks (1, 14, 15).
Radiographic examination
Several projections and angulations are routinely rec­
ommended, but the clinician should decide which radio­
graphs are required for the individual. The following are
suggested:
• Periapical radiograph with a 90° horizontal angle with
central beam through the tooth in question.
• Occlusal view.
• Periapical radiograph with lateral angulations from
the mesial or distal aspect of the tooth in question.
Emerging imaging modalities such as cone-beam
computerized tomography (CBCT) provide enhanced
visualization of TDIs, particularly root fractures and
lateral luxations, monitoring of healing, and complica­
tions. Availability is limited, and its use not currently
considered routine; however, specific information is
available in the scientific literature (16, 17).
Copyright © 2012, International Association of Dental Traumatology, w w w .ia d t-d e n ta ltro u m a .o rg .
Reprinted with permission of the International Association of Dental Traumatology (IADT). D e n ta l T ra u m a to lo g y 2012;28:2-12; d o i: 10.1111/j.1600-9657.2011.01103.\.
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AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
Splinting type and duration
Current evidence supports short-term, non-rigid splints
for splinting of luxated, avulsed, and root-fractured
teeth. While neither the specific type of splint nor the
duration of splinting for root-fractured and luxated teeth
are significantly related to healing outcomes, it is
considered best practice to maintain the repositioned
tooth in correct position, provide patient comfort and
improved function (18, 19).
Use of antibiotics
There is limited evidence for use of systemic antibiotics in
the management of luxation injuries and no evidence
that antibiotic coverage improves outcomes for root-
fractured teeth. Antibiotic use remains at the discretion
of the clinician as TDI’s are often accompanied by soft
tissue and other associated injuries, which may require
other surgical intervention. In addition, the patient’s
medical status may warrant antibiotic coverage (19, 20).
Sensibility tests
Sensibility testing refers to tests (cold test and/or electric
pulp test) attempting to determine the condition of the
pulp. At the time of injury, sensibility tests frequently
give no response indicating a transient lack of pulpal
response. Therefore, at least two signs and symptoms are
necessary to make the diagnosis of necrotic pulp.
Regular follow up controls are required to make a
pulpal diagnosis.
Immature versus mature permanent teeth
Every effort should be made to preserve pulpal vitality
in the immature permanent tooth to ensure continuous
root development. The vast majority of TDIs occur in
children and teenagers where loss of a tooth has
lifetime consequences. The immature permanent tooth
has considerable capacity for healing after traumatic
pulp exposure, luxation injury, and root fractures. Pulp
exposures secondary to TDIs are amenable to proven
conservative pulp therapies that maintain vital pulp
tissue and allow for continued root development (21
24). In addition, emerging therapies have demonstrated
the ability to revascularize/regenerate vital tissue in
canals of immature permanent teeth with necrotic
pulps (25-30). Teeth frequently sustain a combination
of several injuries. Studies have demonstrated that
crown-fractured teeth with or without pulp exposure
and associated luxation injury experience a greater
frequency of pulp necrosis (31). The mature permanent
tooth that sustains a severe TDI after which pulp
necrosis is anticipated is amenable to preventive
pulpectomy as root development is substantially com­
pleted.
Pulp canal obliteration
Pulp canal obliteration (PCO) occurs more frequently in
teeth with open apices which have suffered a severe
luxation injury. It usually indicates ongoing pulpal
vitality. Extrusion, intrusion, and lateral luxation injuries
have high rates of PCO (32, 33) Subluxated and crown-
fractured teeth also may exhibit PCO. although with less
frequency (34). Additionally, PCO is a common occur­
rence following root fractures (35, 36).
ENDORSEMENTS 323
REFERENCE M A N U A L V 37 I NO 6 15/16

Permanent teeth

Follow-up
procedures for Favorable and unfavorable outcomes
fractures of teeth include some, but not necessarily all, of the
1. Treatment guidelines for fractures of teeth and alveolar bone and alveolar bone1 following

Radiographic Unfavorable
Clinical findings findings Treatment Follow up Favorable outcome outcome

Infraction An incomplete No radiographic In case of marked No follow up is Asymptomatic Symptomatic

fracture (crack) of abnormalities infractions, generally needed Positive response Negative response
the enamel Radiographs etching and for infraction to pulp testing to pulp testing
without loss of recommended: sealing with resin injuries unless Continuing root Signs of apical
tooth structure a periapical view. to prevent they are development in periodontitis
Not tender. If Additional discoloration of associated with a immature teeth No continuing root
tenderness is radiographs are the infraction luxation injury or development in
observed evaluate, indicated if lines; otherwise, other fracture immature teeth
the tooth for a other signs or no treatment is types Endodontic
possible luxation symptoms necessary therapy
injury or a root are present appropriate for
fracture stage of root
development is
indicated
Enamel fracture • A complete fracture • Enamel loss is • If the tooth 6 -8 weeks C " • Asymptomatic Symptomatic
of the enamel visible fragment is 1 year C++ • Positive response Negative response
^ ^ jff • Loss of enamel. No • Radiographs available, it can to pulp testing to pulp testing
* m visible sign of recommended: be bonded to the • Continuing root Signs of apical
exposed dentin periapical, tooth development in periodontitis
y y 1 \1 • Not tender. If occlusal, and • Contouring or immature teeth No continuing root
M 11 tenderness is eccentric restoration with • Continue to next development in
I If observed, evaluate exposures. They composite resin evaluation immature teeth
the tooth for a are recommended depending on the Endodontic
possible luxation or in order to rule extent and therapy
root fracture injury out the possible location of the appropriate for
• Normal mobility presence of a fracture stage of root
• Sensibility pulp test root fracture or a development is
usually positive luxation injury indicated
• Radiograph of lip
or cheek to
search for tooth
fragments or
foreign materials

Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltrauma.org.

Reprinted w ith permission of the International Association of Dental Traum atology (IADT). Dental Traumatology 2012;28:2-12; doi: 10.1111/j.1600-9637.2011.01103.x.
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324 ENDORSEMENTS
 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

(Continued)

Follow-up
procedures for Favorable and unfavorable outcomes
fractures of teeth include some, but not necessarily all, of the
1. Treatment guidelines for fractures of teeth and alveolar bone and alveolar bone1 following

Radiographic Favorable Unfavorable

Clinical findings findings Treatment Follow up outcome outcome

Enamel-dentin A fracture confined • Enamel-dentin • If a tooth fragment 6-8 weeks C** • Asymptomatic • Symptomatic
fracture to enamel and loss is visible is available, it can 1 year C " • Positive response • Negative response
dentin with loss of • Radiographs be bonded to the to pulp testing to pulp testing
tooth structure, but recommended: tooth. Otherwise, • Continuing root • Signs of apical
not exposing the periapical, perform a development in periodontitis
pulp occlusal, and provisional immature teeth • No continuing root
Percussion test: eccentric treatment by • Continue to next development in
not tender. If exposure to rule covering the exposed evaluation immature teeth
tenderness is out tooth dentin with glass • Endodontic
observed, evaluate displacement or lonomer or a more therapy
the tooth for possible presence permanent restoration appropriate for
possible luxation of root fracture using a bonding agent stage of root
or root fracture • Radiograph of lip and composite resin, development is
injury or cheek or other accepted indicated
Normal mobility lacerations to dental restorative
Sensibility pulp test search for tooth materials
usually positive fragments or • If the exposed dentin
foreign materials is within 0.5 mm of
the pulp (pink, no
bleeding), place
calcium hydroxide
base and cover with
a material such as
a glass ionomer
Enamel-dentin-pulp A fracture involving • Enamel-dentin • In young patients 6-8 weeks C+* • Asymptomatic • Symptomatic
fracture enamel and dentin loss visible with immature, still 1 year C** • Positive response • Negative response
with loss of tooth • Radiographs developing teeth, it to pulp testing to pulp testing
structure and recommended: is advantageous to • Continuing root • Signs of apical
exposure of the periapical, preserve pulp vitality development in periodontitis
pulp. occlusal, and by pulp capping or immature teeth • No continuing root
Normal mobility eccentric partial pulpotomy. • Continue to next development in
Percussion test: exposures to Also, this treatment evaluation immature teeth
not tender. If rule out tooth is the choice in young • Endodontic
tenderness is displacement or patients with therapy
observed, evaluate possible presence completely formed appropriate for
for possible of root fracture teeth stage of root
luxation or root • Radiograph of lip • Calcium hydroxide is a development is
fracture injury or cheek suitable material to be indicated
Exposed pulp lacerations to placed on the pulp
sensitive to stimuli search for tooth wound in such
fragments or procedures
foreign materials • In patients with mature
apical development,
root canal treatment is
usually the treatment
of choice, although
pulp capping or partial
pulpotomy also may be
selected
If tooth fragment is
available, it can be
bonded to the tooth
Future treatment for
the fractured crown
may be restoration
with other accepted
dental restorative
materials

Copyright © 2012, International Association of Dental Traumatology, www.iodt~dentoltrouma.org.

Reprinted with permission of the International Association of Dental Traumatology (IADT). Dental Traumatology 2012:282-12; doi: 10.im/j.1600-9657.201l.0l103.x.
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ENDORSEMENTS 325
REFERENCE MANUAL V 3 7 /NO 6 15/16

(Continued)

Follow-up
procedures for Favorable and unfavorable outcomes
fractures of teeth include some, but not necessarily all, of the
1. Treatment guidelines for fractures of teeth and alveolar bone and alveolar bone1 following

Radiographic Favorable Unfavorable

Clinical findings findings Treatment Follow up outcome outcome

Crown-root • A fracture • Apical extension Emergency treatment 6-8 weeks C** • Asymptomatic • Symptomatic
fracture involving enamel, of fracture • As an emergency 1 year C” • Positive response • Negative
without dentin, and usually not treatment, a temporary to pulp testing response to pulp
pulp cementum with visible stabilization of the loose • Continuing root testing
exposure loss of tooth • Radiographs segment to adjacent teeth development in • Signs of apical
structure, hut not recommended: can be performed until a immature teeth periodontitis
exposing the pulp periapical, definitive treatment plan is • Continue to next • No continuing
• Crown fracture occlusal, and made evaluation root development
extending below eccentric Non-emergency treatment in immature teeth
i l l gingival margin exposures. alternatives • Endodontic
• Percussion test: They are Fragment removal only therapy
i f
V 1 lV
■
a
tender recommended • Removal of the coronal appropriate for
• Coronal fragment to detect crown-root fragment and stage of root
mobile fracture lines subsequent restoration of development is
• Sensibility pulp in the root the apical fragment indicated
test usually exposed above the
positive for apical gingival level
fragment Fragment removal and
gingivectomy (sometimes
ostectomy)
• Removal of the coronal
crown-root segment with
subsequent endodontic
treatment and restoration
with a post-retained
crown. This procedure
should be preceded by a
gingivectomy, and
sometimes ostectomy
with osteoplasty
Orthodontic extrusion of
apical fragment
• Removal of the coronal
segment with subsequent
endodontic treatment and
orthodontic extrusion of
the remaining root with
sufficient length after
extrusion to support a
post-retained crown
Surgical extrusion
• Removal of the mobile
fractured fragment with
subsequent surgical
repositioning of the root
in a more coronal position
Root submergence
• Implant solution is
planned
Extraction
• Extraction with immediate
or delayed
implant-retained crown
restoration or a
conventional bridge.
Extraction is inevitable in
crown-root fractures with
a severe apical extension,
the extreme being a
vertical fracture

Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltrauma.org.

Reprinted with permission of the international Association of Dental Traumatology (IADT). Dental Traumatology 2012;28:2-12; doi: 10.l1l1/j.1600-9657.201l.0ll03.x.
Available at http://onlinelibrary.wiley.eom/doi/10.ini/j.1600-9657.2011.01103.x/full.

326 ENDORSEMENTS
 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

(Continued)

Follow-up
procedures
fo r fractures Favorable and unfavorable outcomes
of teeth and include some, but not necessarily all,
1. Treatment guidelines for fractures of teeth and alveolar bone alveolar bone1 of the following

Clinical Radiographic Favorable Unfavorable

findings findings Treatment Follow up outcome outcome

Crown-root • A fracture • Apical Emergency treatment 6 -8 weeks C " • Asymptomatic • Symptomatic

fracture involving extension • As an emergency treatment a 1 year C+* • Positive • Negative
with pulp enamel, dentin, of fracture temporary stabilization of the response to response to
exposure and cementum usually not loose segment to adjacent teeth pulp testing pulp testing
and exposing visible • In patients with open apices, it • Continuing root • Signs of
1 the • Radiographs is advantageous to preserve development apical
ii&A ' pulp
• Percussion
recommended:
periapical
pulp vitality by a partial
pulpotomy. This treatment is
in immature
teeth
periodontitis
• No continuing
V ,* V /
v
m r '1 test: tender
• Coronal
and occlusal
exposure
also the choice in young
patients with completely formed
• Continue to
next evaluation
root development
in immature teeth
fragment teeth. Calcium hydroxide • Endodontic
mobile compounds are suitable pulp therapy
capping materials. In patients appropriate for
with mature apical development, stage of root
root canal treatment can be the development is
treatment of choice indicated
Non-Emergency Treatment
Alternatives
Fragment removal and
gingivectomy (sometimes
osteotomy)
Removal of the coronal fragment
with subsequent endodontic
treatment and restoration with a
post-retained crown. This
procedure should be preceded by
a gingivectomy and sometimes
osteotomy with osteoplasty. This
treatment option is only indicated
in crown-root fractures with
palatal subgingival extension
Orthodontic extrusion of apical
fragment
Removal of the coronal segment
with subsequent endodontic
treatment and orthodontic
extrusion of the remaining root
with sufficient length after
extrusion to support a
post-retained crown
Surgical extrusion
Removal of the mobile fractured
fragment with subsequent surgical
repositioning of the root in a more
coronal position
Root submergence
An implant solution is planned, the
root fragment may be left in situ
Extraction
Extraction with immediate or
delayed implant-retained crown
restoration or a conventional
bridge. Extraction is inevitable in
very deep crown-root fractures,
the extreme being a vertical
fracture

Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltrauma.org.

Reprinted with permission of the International Association of Dental Traumatology (IADT). Dental Traumatology 2012;28:2-12; doi: 10.l111/].1600-9657.201l.01103.x.
Available a thttp://onlinelibrary.wiley.eom/doi/10.im/j.1600-9657.20ll.0m3.x/full.

ENDORSEMENTS 327
REFERENCE MANUAL V 37 / NO 6 15/16

(Continued)

Follow-up
procedures Favorable and unfavorable outcomes
for luxated include some, but not necessarily all,
2. Treatment guidelines for luxation injuries permanent teeth of the following2

Radiographic Favorable Unfavorable

Clinical findings findings Treatment Follow up outcome outcome

Root fracture • The coronal • The fracture • Reposition, if 4 weeks S4, C44 • Positive response • Symptomatic
segment may be involves the root displaced, the coronal 6-8 weeks C44 to pulp testing • Negative
mobile and may of the tooth and segment of the tooth 4 months S44, C44 (false negative response to pulp
be displaced is in a horizontal as soon as possible 6 months C44 possible up to testing (false
• The tooth may be or oblique plane • Check position 1 year C44 3 months) negative possible
tender to • Fractures that are radiographically 5 years C44 • Signs of repair up to 3 months)
percussion in the horizontal • Stabilize the tooth between fractured • Extrusion of the
• Bleeding from the plane can usually with a flexible splint segments coronal segment
gingival sulcus be detected in the for 4 weeks. If the • Continue to next • Radiolucency at
may be noted regular periapical root fracture is near evaluation the fracture line
• Sensibility testing 90° angle film the cervical area of • Clinical signs of
may give negative with the central the tooth, stabilization periodontitis or
results initially, beam through the is beneficial for a abscess
indicating tooth. This is longer period of time associated with
transient or usually the case (up to 4 months) the fracture line
permanent neural with fractures in • It is advisable to • Endodontic
damage the cervical third monitor healing for at therapy
• Monitoring the of the root least 1 year to appropriate for
status of the pulp • If the plane of determine pulpal stage of root
is recommended fracture is more status development is
• Transient crown oblique, which is • If pulp necrosis indicated
discoloration (red common with develops, root canal
or gray) may apical third treatment of the
occur fractures, an coronal tooth
occlusal view or segment to the
radiographs with fracture line is
varying horizontal indicated to preserve
angles is more the tooth
likely to
demonstrate the
fracture including
those located in
the middle third
Alveolar fracture • The fracture • Fracture lines • Reposition any 4 weeks S4, C44 • Positive response • Symptomatic
involves the may be located at displaced segment 6-8 weeks C44 to pulp testing • Negative
alveolar bone and any level, from and then splint 4 months C44 (false negative response to pulp
may extend to the marginal bone • Suture gingival 6 months C44 possible up to testing (false
adjacent bone to the root apex laceration if present 1 year C44 3 months) negative possible
• Segment mobility • In addition to the • Stabilize the 5 years C44 • No signs of apical up to 3 months)
and dislocation 3 angulations and segment for 4 weeks periodontitis • Signs of apical
with several teeth occlusal film, • Continue to next periodontitis or
moving together additional views evaluation external
are common such as a inflammatory root
findings panoramic resorption
• An occlusal radiograph can be • Endodontic
change because helpful in therapy
of misalignment determining the appropriate for
the fractured course and stage of root
alveolar segment position of the development is
is often noted fracture lines indicated
• Sensibility testing
may or may not
be positive

Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltrauma.org.

Reprinted with permission of the International Association of Dental Traumatology (IADT). Dental Traumatology 2012;28:2-12; doi: I0.1l1l/j.1600-9657.2011.0n03.x.
Available at http://onlinelibrary.wiley.eom/doi/l0.llll/j.l600-9657.20ll.0H03.x/full.

328 ENDORSEMENTS
 AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

(Continued)

Follow-up
procedures Favorable and unfavorable outcomes
for luxated include some, but not necessarily all,
2. Treatment guidelines for luxation injuries permanent teeth of the following2

Radiographic Favorable Unfavorable

Clinical findings findings Treatment Follow up outcome outcome

Concussion The tooth is tender • No radiographic • No treatment is 4 weeks C " • Asymptomatic • Symptomatic
to touch or tapping; abnormalities needed 6-8 weeks C"* • Positive response • Negative response
it has not been • Monitor pulpal 1 year C*+ to pulp testing to pulp testing
displaced and does condition for at • False negative • False negative
not have increased least 1 year possible up to possible up to
mobility 3 months 3 months
Sensibility tests are • Continuing root • No continuing root
likely to give development in development in
positive results immature teeth immature teeth,
• Intact lamina dura signs of apical
periodontitis
• Endodontic therapy
appropriate for
stage of root
development is
indicated
Subluxation The tooth is tender • Radiographic • Normally no 2 weeks S \ C* * • Asymptomatic • Symptomatic
to touch or tapping abnormalities are treatment is 4 weeks C** • Positive response • Negative response
and has increased usually not found needed; however. 6-8 weeks C** to pulp testing to pulp testing
mobility; it has not a flexible splint to 6 months C*+ • False negative • False negative
been displaced stabilize the tooth 1 year C " possible up to possible up to
Bleeding from for patient 3 months 3 months
gingival crevice comfort can be • Continuing root • External
may be noted used for up to development in inflammatory
Sensibility testing 2 weeks immature teeth resorption
may be negative • Intact lamina dura • No continuing root
initially indicating development in
transient pulpal immature teeth,
damage signs of apical
Monitor pulpal periodontitis
response until a • Endodontic therapy
definitive pulpal appropriate for
diagnosis can be stage of root
made development is
indicated
Extrusive luxation The tooth appears • Increased • Reposition the 2 weeks S*1 C " • Asymptomatic • Symptoms and
elongated and is periodontal tooth by gently 4 weeks C*+ • Clinical and radiographic sign
excessively mobile ligament re-inserting It into 6-8 weeks C** radiographic consistent with
Sensibility tests will space apically the tooth socket 6 months C " signs of normal apical periodontitis
likely give negative • Stabilize the tooth 1 year Ct+ or healed • Negative response
results for 2 weeks using Yearly 5 years C” periodontium to pulp testing
a flexible splint • Positive response (false negative
• In mature teeth to pulp testing possible up to
where pulp (false negative 3 months)
necrosis is possible up to • If breakdown of
anticipated or if 3 months) marginal bone,
several signs and • Marginal bone splint for an
symptoms height additional
indicate that the corresponds to 3-4 weeks
pulp of mature or that seen • External
immature teeth radiographically inflammatory root
became necrotic, after resorption
root canal repositioning • Endodontic therapy
treatment is • Continuing root appropriate for
indicated development in stage of root
immature teeth development is
indicated

Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltraumo.org.

Reprinted with permission of the International Association of Dental Traumatology (IADT). Dental Traumatology 201228:2-12: doi: 10.li ll / j . 1600-9657.2011.01103.x.
Available a t http://onlinelibrary.wiley.eom/doi/10.llll/j.1600-96572011.01103.x/full.

ENDORSEMENTS 329
REFERENCE MANUAL V 37 I NO 6 15 116

(Continued)

Follow-up
procedures Favorable and unfavorable outcomes
for luxated include some, but not necessarily all,
2. Treatment guidelines for luxation injuries permanent teeth of the following2

Radiographic Favorable Unfavorable

linical findings findings T reatment Follow up outcome outcome

Lateral Luxation The tooth is • The widened • Reposition the tooth 2 weeks S4, • Asymptomatic • Symptoms and
displaced, usually periodontal digitally or with C44 • Clinical and radiographic signs
in a palatal/linguai ligament space forceps to disengage 4 weeks C44 radiographic consistent with
or labial direction is best seen on it from its bony lock 6-8 weeks C44 signs of normal apical periodontitis
It will be eccentric or and gently 6 months C44 or healed • Negative response to
immobile and occlusal reposition it into 1 year C44 periodontium pulp testing (false
percussion exposures its original location Yearly for 5 • Positive response negative possible
usually gives a • Stabilize the tooth years C44 to pulp testing up to 3 months)
high, metallic for 4 weeks using a (false negative • If breakdown of
(ankylotic) sound flexible splint possible up to marginal bone, splint
Fracture of the • Monitor the pulpal 3 months) for an additional
alveolar process condition • Marginal bone 3-4 weeks
present • If the pulp becomes height • External
Sensibility tests necrotic, root canal corresponds to inflammatory root
will likely give treatment is indicated that seen resorption or
negative results to prevent root radiographically replacement resorption
resorption after • Endodontic therapy
repositioning appropriate for
• Continuing root stage of root
development in development is
immature teeth indicated
Intrusive luxation The tooth is • The periodontal Teeth with incomplete root 2 weeks S4, • Tooth in place • Tooth locked in
displaced axially ligament space formation C44 or erupting place/ankylotic tone
into the alveolar may be absent • Allow eruption without 4 weeks C44 • Intact lamina to percussion
bone from all or part intervention 6-8 weeks C44 dura • Radiographic signs
It is immobile, of the root • If no movement within 6 months C44 • No signs of of apical
and percussion • The cemento- few weeks, initiate 1 year C44 resorption periodontitis
may give a high, enamel junction orthodontic repositioning Yearly for 5 • Continuing root • External
metallic is located more • If tooth is intruded more years C44 development in inflammatory root
(ankylotic) sound apically in the than 7 mm, reposition immature teeth resorption or
Sensibility tests intruded tooth surgically or orthodontically replacement
will likely give than in adjacent Teeth with complete root resorption
negative results non-injured teeth, formation • Endodontic therapy
at times even • Allow eruption without appropriate for
apical to the intervention if tooth stage of root
marginal bone intruded less than 3 mm. development is
level If no movement after 2-4 indicated
weeks, reposition surgically
or orthodontically before
ankylosis can develop
If tooth is intruded beyond
7 mm, reposition surgically
The pulp will likely become
necrotic in teeth with
complete root formation.
Root canal therapy using
a temporary filling with
calcium hydroxide is
recommended and
treatment should begin
2-3 weeks after surgery
Once an intruded tooth
has been repositioned
surgically or orthodontically,
stabilize with a flexible
splint for 4-8 weeks

C44, clinical and radiographic examination; S4, splint removal; S44, splint removal in cervical third fractures.
1For crown-fractured teeth with concomitant luxation injury, use the luxation follow-up schedule.
2Whenever there is evidence of external inflammatory root resorption, root canal therapy should be initiated immediately, with the use of calcium hydroxide as an
intra-canal medication.

Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltrauma.org.

Reprinted with permission of the International Association of Dental Traumatology (IADT). Dental Traumatology 2012;28:2-12; doi: I0.1ll1/j.l600-9657.20l1.01103.x.
Available at http://onlinelibrary.wiley.eom/doi/W.lW/j.1600-9657.20n.01W3.x/full.

330 ENDORSEMENTS

Patient instructions
Patient compliance with follow-up visits and home care
contributes to better healing following a TDI. Both
patients and parents of young patients should be
advised regarding care of the injured tooth/teeth for
optimal healing, prevention of further injury by avoid­
ance of participation in contact sports, meticulous oral
hygiene, and rinsing with an antibacterial such as
chlorhexidine gluconate 0.1% alcohol free for
1-2 weeks.
Additional resources
Besides the general recommendations mentioned earlier,
clinicians are encouraged to access the DTG, the journal
Dental Traumatology, and other journals for informa­
tion pertaining to treatment delay (37), intrusive
luxations 38-47), root fractures (48-52), pulpal manage­
ment of fractured and luxated teeth (34, 53-64, splinting
(18, 39, 65-68), and antibiotics (69).
A c kn o w led g e m e n ts
IADT is grateful to the team of Dental Trauma Guide
www.dentaltraumaguide.org for kindly providing
pictures to the article.
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Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltrauma.org.
Reprinted with permission of the International Association of Dental Traumatology (IADT). Dental Traumatology 2012;28:2-12; doi: 10.1111/j.1600-9657.2011.01103.x.
Available at http://onlinelibrary.wiley.eom/doi/l0.IIH/j.l600-965720ll.0IW3.x/full.
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Dent Traumatol 2012;28:499
In DiAngelis et al. (1), the following corrections should be made:
Under the heading ‘Follow up’ for both lateral luxation and intrusion, the first two
time periods should be read as:
• 2 weeks, C++ (not 2 weeks S+, C++)
• 4 weeks S+, C++ (not 4 weeks C++)
This makes splint removal at 4 weeks consistent with what is recommended under
‘Treatment’.
Under ‘Treatment’, ‘Teeth with complete root formation’, there should be an addi­
tional second bullet to read as:
Copyright © 2012, International Association of Dental Traumatology, www.iadt-dentaltrauma.org.
Reprinted with permission of the International Association of Dental Traumatology (IADT). Dental Traumatology 2012;28:2-12; doi: 10.1111/j.1600-9657.2011.01103.x.
Available at http://onlinelibrary.wiley.eom/doi/10.1111/j.1600-9657.2011.0n03.x/full.
332 ENDORSEMENTS
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92.
• if tooth is intruded 3-7 mm, reposi tion surgically or orthodontically
The last word in the fourth bulleted sentence should be repositioning instead of
surgery.
The authors would like to apologize for these errors.
Reference
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of Dental Traumatology guidelines for the management of traumatic dental
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