International Association of Dental Traumatology guidelines for the management of

Accepted Article
traumatic dental injuries: 1. Fractures and luxations.

Cecilia Bourguignon1, Nestor Cohenca2, Eva Lauridsen3, Marie Therese Flores4, Anne O'Connell5,
Peter Day6, Georgios Tsilingaridis7, Paul V. Abbott8, Ashraf F. Fouad9, Lamar Hicks10, Jens Ove
Andreasen11, Zafer C. Cehreli12, Stephen Harlamb13, Bill Kahler14, Adeleke Oginni15, Marc
Semper16, Liran Levin17.

1Private Practice, Paris, France.

2Department of Pediatric Dentistry, University of Washington and Seattle Children’s Hospital. Seattle, WA

3Resource Center for Rare Oral Diseases, Copenhagen University Hospital, Denmark.

4Department of Pediatric Dentistry, Faculty of Dentistry, Universidad de Valparaíso, Valparaíso, Chile.

5Paediatric Dentitsry, Dublin Dental University Hospital, Trinity College Dublin, The University of Dublin, Ireland.

6School of Dentistry at the University of Leeds and Community Dental Service Bradford District Care NHS Trust.

7 Karolinska Institutet, Department of Dental Medicine, Division of Orthodontics and Pediatric Dentistry, Huddinge &

Center for Pediatric Oral Health Research, Stockholm, Sweden.

8UWA Dental School, University of Western Australia.

9Adams School of Dentistry, University of North Carolina, Chapel Hill, NC, USA.

10Division of Endodontics, University of Maryland School of Dentistry, UMB, Baltimore, Maryland, USA.

11Resource Centre for Rare Oral Diseases, Department of Oral and Maxillofacial Surgery, University Hospital in

Copenhagen (Rigshospitalet), Copenhagen, Denmark.

12 Department of Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey.

13 Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.

14 School of Dentistry, The University of Queensland, Australia.

15 Faculty of Dentistry, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria.

16 Specialist Private Practice, Bremen, Germany.

17Faculty of Medicine and Dentistry, University of Alberta, Canada.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/EDT.12578
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 Keywords: Trauma, avulsion, tooth fracture, prevention, luxation
Accepted Article
Short title: IADT traumatic dental injuries guidelines: Fractures and luxations

Correspondence and reprint requests to:

Prof. Liran Levin – Chair of the IADT Guidelines Committee
University of Alberta, Faculty of Medicine & Dentistry
5-468 Edmonton Clinic Health Academy
11405 - 87 Avenue NW, 5th Floor
Edmonton AB T6G 1C9
E-mail: [email protected]

Acknowledgement and Competing Interest

The authors declare there are no competing interest for the above manuscript. No funding was
received for the presented work.
Images Courtesy of the Dental Trauma Guide
Ethical Statement – No ethic approval was required for this paper.

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Accepted Article
PROFESSOR NESTOR COHENCA (Orcid ID : 0000-0002-0603-5437)
DR EVA LAURIDSEN (Orcid ID : 0000-0003-0859-7262)
PROFESSOR MARIE THERESE FLORES (Orcid ID : 0000-0003-2412-190X)
DR GEORGIOS TSILINGARIDIS (Orcid ID : 0000-0001-5361-5840)
PROFESSOR PAUL VINCENT ABBOTT (Orcid ID : 0000-0001-5727-4211)
PROFESSOR ASHRAF F. FOUAD (Orcid ID : 0000-0001-6368-1665)
DR BILL KAHLER (Orcid ID : 0000-0002-4181-3871)
PROFESSOR LIRAN LEVIN (Orcid ID : 0000-0002-8123-7936)

Article type : Comprehensive Review

International Association of Dental Traumatology guidelines for the

management of traumatic dental injuries: 1. Fractures and luxations.

Abstract:
Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young
adults. Crown fractures and luxations of these teeth are the most commonly occurring of all
dental injuries. Proper diagnosis, treatment planning and follow up are important for achieving
a favorable outcome. Guidelines should assist dentists and patients in decision making and in
providing the best care possible, both effectively and efficiently. The International Association
of Dental Traumatology (IADT) has developed these Guidelines as a consensus statement after
a comprehensive review of the dental literature and working group discussions. Experienced
researchers and clinicians from various specialties and the general dentistry community were
included in the working group. In cases where the published data did not appear conclusive,
recommendations were based on the consensus opinions of the working group. They were then

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Accepted Article
reviewed and approved by the members of the IADT Board of Directors. These Guidelines
represent the best current evidence based on literature search and expert opinion. The primary
goal of these Guidelines is to delineate an approach for the immediate or urgent care of TDIs. In
this first article, the IADT Guidelines cover the management of fractures and luxations of
permanent teeth.
The IADT does not, and cannot, guarantee favorable outcomes from adherence to the
Guidelines. However, the IADT believes that their application can maximize the probability of
favorable outcomes.

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Accepted Article
Introduction:
The vast majority of traumatic dental injuries (TDI) occur in children and teenagers where loss of
a tooth has lifetime consequences. Treatments for these younger age groups may be different than in
adults, mainly due to immature teeth and pubertal facial growth. The purpose of these Guidelines is to
improve management of injured teeth and minimize complications resulting from trauma.

Clinical examination
Trauma involving the dento-alveolar region is a frequent occurrence which can result in the
fracture and displacement of teeth, crushing and/or fracturing of bone, and soft tissue injuries including
contusions, abrasions and lacerations. Available current literature provides protocols, methods and
documentation for the clinical assessment of Traumatic Dental Injuries (TDI), trauma first aid, patient
examination, factors that affect treatment planning decisions and the importance of communicating
treatment options and prognosis to traumatized patients.1-3
The combination of two different types of injuries occurring concurrently to the same tooth will
be more detrimental than a single injury, creating a negative synergistic effect. Concurrent crown
fractures significantly increase the risk of pulp necrosis and infection in teeth with concussion or
subluxation injuries and mature root development.4 Similarly, crown fractures with or without pulp
exposure significantly increase the risk of pulp necrosis and infection in teeth with lateral luxation.5, 6
Kenny et al. have developed a core outcome set (COS) for TDIs in children and adults.7
Outcomes were identified as recurring throughout the different injury types. These outcomes were then
identified as “generic” or “Injury-specific”. “Generic outcomes are relevant to all TDIs while “Injury-
specific outcomes” are related to only one or more specific TDIs. Additionally, the core outcome set also
established what, how, when and by whom these outcomes should be measured.

Radiographic examination
Several conventional two-dimensional imaging projections and angulations are recommended.2,9,10
The clinician should evaluate each case and determine which radiographs are required for the specific
case involved. A clear justification for taking a radiograph is essential. There needs to be a strong
likelihood that a radiograph will provide the information that will positively influence the selection of

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 the treatment provided. Furthermore, initial radiographs are important as they provide a baseline for
Accepted Article
future comparisons at follow-up examinations. The use of film holders is highly recommended to allow
standardization and reproducible radiographs.

Since maxillary central incisors are the most frequently affected teeth, the radiographs listed below
are recommended to thoroughly examine the injured area:
1. One parallel periapical radiograph aimed through the midline to show the two maxillary
central incisors
2. One parallel periapical radiograph aimed at the maxillary right lateral incisors (should also
show the right canine and central incisor)
3. One parallel periapical radiograph aimed at the maxillary left lateral incisor (should also show
the left canine and central incisor)
4. One maxillary occlusal radiograph
5. At least one parallel periapical radiograph of the lower incisors centered on the two
mandibular centrals. However, other radiographs may be indicated if there are obvious
injuries of the mandibular teeth (e.g. similar periapical radiographs as above for the maxillary
teeth, mandibular occlusal radiograph).
The radiographs aimed at the maxillary lateral incisors provide different horizontal (mesial and distal)
views of each incisor, as well as showing the canine teeth. The occlusal radiograph provides a different
vertical view of the injured teeth and the surrounding tissues, which is particularly helpful in the
detection of lateral luxations, root fractures and alveolar bone fractures.2,9,10

The above radopgraphic series is provided as an example. If other teeth are injured, then the series
can be modified to focus on the relevant tooth/teeth. Simple injuries, such as enamel infractions,
uncomplicated crown fractures and complicated crown fractures, may not require all of these
radiographs.

Radiographs are necessary to make a thorough diagnosis of dental injuries. Tooth root and bone
fractures, for instance, may occur without any clinical signs or symptoms and are frequently undetected
when only one radiographic view is used. Additionally, patients sometimes seek treatment several
weeks after the trauma occurred when clinical signs of a more serious injury have subsided. Thus,

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 dentists should use their clinical judgement and weigh the advantages and disadvantages of taking
Accepted Article
several radiographs.

Cone beam computerized tomography (CBCT) provides enhanced visualization of TDIs, particularly
root fractures, crown/root fractures and lateral luxations. CBCT helps to determine the location, extent
and direction of a fracture. In these specific injuries, 3D imaging can be useful and should be considered,
if available.10-12 A guiding principle when considering exposing a patient to ionizing radiations (e.g. either
2D or 3D radiographs) is whether the image is likely to change the management of the injury.

Photographic documentation
The use of clinical photographs is strongly recommended for the initial documentation of the
injury and for follow-up examinations. Photographic documentation allows monitoring of soft tissue
healing, assessment of tooth discoloration, the re-eruption of an intruded tooth, and the development
of infra-positioning of an ankylosed tooth. In addition, photographs provide medico-legal
documentation that could be used in litigation cases.

Pulp status evaluation: sensibility and vitality testing

 Sensibility tests
Sensibility testing refers to tests (cold test and electric pulp test) used to determine the
condition of the pulp. It is important to understand that sensibility testing assesses neural activity and
not vascular supply. Thus, this testing might be unreliable due to a transient lack of neural response or
undifferentiation of A-delta nerve fibres in young teeth. 13-15 The temporary loss of sensibility is a
frequent finding during post-traumatic pulp healing, especially after luxation injuries.16 Thus, the lack of
a response to pulp sensibility testing is not conclusive for pulp necrosis in traumatized teeth.17-20 Despite
this limitation, pulp sensibility testing should be performed initially and at each follow up appointment
in order to determine if changes occur over time. It is generally accepted that pulp sensibility testing
should be done as soon as practical to establish a baseline for future comparison testing and follow up.
Initial testing is also a good predictor for the long-term prognosis of the pulp.13-16, 21

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Accepted Article  Vitality tests
The use of pulse oximetry, which measures actual blood flow rather than the neural response,
has been shown to be a reliable non-invasive and accurate way of confirming the presence of a blood
supply (vitality) in the pulp.15, 22 The current use of pulse oximetry is limited due to the lack of sensors
specifically designed to fit dental dimensions and the lack of power to penetrate through hard dental
tissues.
Laser and Ultrasound Doppler Flowmetry are promising technologies to monitor pulp vitality.

Stabilization/Splinting: Type and duration

Current evidence supports short-term, passive and flexible splints for splinting of luxated,
avulsed and root-fractured teeth. In the case of alveolar bone fractures, splinting of the teeth may be
used for bone segment immobilization. When using wire-composite splints, physiologic stabilization can
be obtained with stainless steel wire up to 0.4mm in diameter.23 Splinting is considered best practice in
order to maintain the repositioned tooth in its correct position and to favor initial healing while
providing comfort and controlled function. 24-26 It is critically important to keep composite and bonding
agents away from the gingiva and proximal areas to avoid plaque retention and secondary infection.
This allows better healing of the marginal gingiva and bone. Splinting time (duration) will depend on the
injury type. Please see the recommendations for each injury type.

Use of antibiotics
There is limited evidence for the use of systemic antibiotics in the emergency management of
luxation injuries and no evidence that antibiotics improve the outcomes for root fractured teeth.
Antibiotic use remains at the discretion of the clinician as TDIs 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.27, 28

Patient instructions

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 Patient compliance with follow-up visits and home care contribute to better healing following a
Accepted Article
TDI. Both patients and parents or guardians should be advised regarding care of the injured tooth/teeth
and tissues for optimal healing, prevention of further injury by avoidance of participation in contact
sports, meticulous oral hygiene and rinsing with an antibacterial agent such as chlorhexidine gluconate
0.12%.

Follow-ups and detection of post-traumatic complications

Follow-ups are mandatory after traumatic injuries. Each follow-up should include
questioning of the patient about any signs or symptoms, plus clinical and radiographic
examinations and pulp sensibility testing. Photographic documentation is strongly
recommended. The main post-traumatic complications are: pulp necrosis and infection, pulp
space obliteration, several types of root resorption, breakdown of marginal gingiva and bone.
Early detection and management of complications improves prognosis.

Stage of root development - Immature (open apex) versus Mature (closed apex)
permanent teeth
Every effort should be made to preserve the pulp, in both mature and immature teeth.
In immature permanent teeth this is of utmost importance in order to allow continued root
development and apex formation. The vast majority of TDIs occur in children and teenagers,
where loss of a tooth has lifetime consequences. The pulp of an immature permanent tooth
has considerable capacity for healing after a traumatic pulp exposure, luxation injury or root
fracture. Pulp exposures secondary to TDIs are amenable to conservative pulp therapies, such
as pulp capping, partial pulpotomy, shallow or partial pulpotomy and cervical pulpotomy, which
aim to maintain the pulp and allow for continued root development.29-32 In addition, emerging
therapies have demonstrated the ability to revascularize/revitalize teeth by attempting to
create conditions allowing for tissue in-growth into the root canals of immature permanent
teeth with necrotic pulps.33-38

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Accepted Article
Combined injuries
Teeth frequently sustain a combination of several injuries. Studies have demonstrated
that crown fractured teeth, with or without pulp exposure and with a concomitant luxation
injury, experience a greater frequency of pulp necrosis and infection.39 Mature permanent
teeth that sustain a severe TDI after which pulp necrosis and infection is anticipated are
amenable to preventive endodontic treatment.
Since prognosis is worse in combined injuries, the more frequent follow-up regimen for
luxation injuries prevails over the less frequent regime for fractures.

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 the presence of viable pulp tissue
within the root canal. Extrusion, intrusion and lateral luxation injuries have high rates of
PCO.40,41 Subluxated and crown fractured teeth also may exhibit PCO, although with lower
frequency.42 Additionally, PCO is a common occurrence following root fractures.8,43

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Accepted Article
Endodontic considerations for luxated and fractured teeth

Fully developed teeth (mature teeth with closed apex):

The pulp may survive after the trauma, but early endodontic treatment is typically advisable for
fully developed teeth that have been intruded, severely extruded or laterally luxated. Calcium
hydroxide is recommended as an intra-canal medicament to be placed 1 to 2 weeks after
trauma for up to 1 month followed by root canal filling.44 Alternately, a corticosteroid/antibiotic
paste can be used as an anti-inflammatory and anti-resorptive intracanal medicament to
prevent external inflammatory (infection-related) resorption. If such a paste is used, it should
be placed immediately (or as soon as possible) following repositioning of the tooth and then
left in situ for at least 6 weeks.45-48 Medicaments should be carefully applied within the root
canal system while avoiding contact with the access cavity walls due to possible discoloration of
the crown.48

Incompletely developed teeth (immature teeth with open apex):

The pulp of fractured and luxated immature teeth may survive and heal, or there may be
spontaneous pulp revascularization following luxation. Thus, root canal treatment should be
avoided unless there is clinical or radiographic evidence of pulp necrosis or periapical infection
on follow-up examinations. The risk of infection-related (inflammatory) root resorption should
be weighed against the chances of obtaining pulp space revascularization. Such resorption is
very rapid in children. Hence, regular follow-ups are mandatory so root canal treatment can be
commenced as soon as this type of resorption is detected (see below). Incompletely developed
teeth that have been intruded and also have a crown fracture (combined traumatic injuries) are
at higher risk of pulp necrosis and infection and, therefore, immediate or early root canal
treatment should be considered in these cases. Other endodontic treatment of teeth with
incompletely developed roots may involve apexification or pulp space
revascularization/revitalization techniques.

Endodontic treatment for external inflammatory (infection-related) root resorption:

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Accepted Article
Whenever there is evidence of infection-related (inflammatory) external resorption, root canal
treatment should be initiated immediately. The canal should be medicated with calcium
hydroxide.49

Dental dam field isolation during endodontic treatment:

Endodontic treatment should always be undertaken under dental dam isolation. The dental
dam retainer can be applied on one or more neighboring teeth to avoid further trauma to the
injured tooth/teeth and to prevent the risk of fracturing an immature tooth. Dental floss or
other stabilizing cords may also be used instead of metal retainers.

Core Outcome Set:

The International Association for Dental Traumatology (IADT) recently developed a core
outcome set (COS) for traumatic dental injuries (TDIs) in children and adults.7 This is one of the
first COS developed in dentistry and is underpinned by a systematic review of the outcomes
used in the trauma literature and follows a robust consensus methodology. Some outcomes
were identified as recurring throughout the different injury types. These outcomes were then
identified as “generic” (i.e. relevant to all TDIs). Injury-specific outcomes were also determined
as those outcomes related only to one or more individual TDIs. Additionally, the study
established what, how, when and by whom these outcomes should be measured. Table 2 in the
General Introduction section of the Guidelines shows the generic and injury specific outcomes
to be recorded at the follow-up review appointments recommended for the different traumatic
injuries. Further information for each outcome is described in the original article 7 with
supplementary materials available on the Dental Traumatology journal’s website.

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Accepted Article
Additional resources
Besides the general recommendations above, clinicians are encouraged to access the
IADT’s official publication, the journal Dental Traumatology, the IADT website (www.iadt-
dentaltrauma.org), the free ToothSOS app and the Dental Trauma Guide
(www.dentaltraumaguide.org).

Other useful references include textbooks and other scientific publications for
information pertaining to treatment delay,50 intrusive luxations,51-53 root fractures,26, 54-57 pulp
management of fractured and luxated teeth,1, 38, 42, 58-63 splinting,23, 24, 64, 65 and antibiotics.27, 28

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Accepted Article
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Accepted Article
PERMANENT TEETH

Table 1 – Treatment guidelines for enamel infractions

Imaging, Radiographic
ENAMEL INFRACTION Clinical Findings Treatment Follow-Up Favorable Outcomes Unfavorable Outcomes
Assessment and Findings

 No sensitivity to  No radiographic abnormalities  In case of severe infractions,  No follow-up is needed if  Asymptomatic  Symptomatic
percussion or palpation etching and sealing with it is certain that the
 Recommended radiographs:  Positive response  Pulp necrosis and
bonding resin should be tooth suffered an
 Evaluate the tooth for a to pulp sensibility infection
- One parallel periapical considered to prevent infraction injury only
possible associated testing
radiograph discoloration and bacterial  Apical periodontitis
luxation injury or root  If there is an associated
contamination of the  Continued root
fracture, especially if - Additional radiographs are injury such as a luxation  Lack of further root
infractions. development in
tenderness is observed indicated if signs or injury, that injury- development in
immature teeth
symptoms of other immature teeth
An incomplete fracture  Otherwise, no treatment is specific follow-up
 Normal mobility
potential injuries are necessary regimen prevails*
(crack or crazing) of the
 Pulp sensibility tests present
enamel, without loss of
usually positive
tooth structure

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Accepted Article

* = For teeth with infractions plus a concomitant luxation injury, use the luxation injury follow-up schedule

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Accepted Article
Table 2 – Treatment guidelines for uncomplicated crown fractures involving enamel only

UNCOMPLICATED CROWN
Imaging, Radiographic
FRACTURE Clinical Findings Treatment Follow-up Favorable Outcomes Unfavorable Outcomes
Assessment and Findings
(Enamel-Only Fracture)

 Loss of enamel  Enamel loss is visible  If the tooth fragment is available, Clinical and radiographic  Asymptomatic  Symptomatic
it can be bonded back on to the evaluations are
 No visible sign of  Missing fragments should be  Positive response to  Pulp necrosis and
tooth necessary:
exposed dentin accounted for: pulp sensibility infection
 Alternatively, depending on the  after 6-8 weeks testing
 Evaluate the tooth for a - If fragment is missing and  Apical periodontitis
extent and location of the
possible associated there are soft tissue  after 1 year  Good quality
fracture, the tooth edges can be  Loss of restoration
luxation injury or root injuries, radiographs of restoration
smoothed, or a composite resin  If there is an
fracture, especially if the lip and/or cheek are  Breakdown of the
restoration placed associated luxation or  Continued root
A coronal fracture involving tenderness is present indicated to search for restoration
root fracture, or the development in
enamel only, with loss of tooth fragments and/or
 Normal mobility suspicion of an immature teeth  Lack of further root
tooth structure foreign materials
associated luxation development in
 Pulp sensibility tests
 Recommended radiographs: injury, the luxation immature teeth
usually positive
follow-up regimen
- One parallel periapical
prevails and should be
radiograph
used* Longer follow-
- Additional radiographs ups will be needed
are indicated if signs or
symptoms of other
potential injuries are

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Accepted Article
present

* = For crown fractured teeth with concomitant luxation injury, use the luxation follow-up schedule

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Accepted Article
Table 3 – Treatment guidelines for uncomplicated crown fractures involving enamel and dentine

UNCOMPLICATED CROWN
Imaging, Radiographic
FRACTURE Clinical Findings Treatment Follow-Up Favorable Outcomes Unfavorable Outcomes
Assessment and Findings
(Enamel-Dentin Fracture)

 Normal mobility  Enamel-dentin loss is visible.  If the tooth fragment is available Clinical and radiographic  Asymptomatic  Symptomatic
and intact, it can be bonded back evaluations are necessary:
 Pulp sensibility tests  Missing fragments should be  Positive response to  Pulp necrosis and
on to the tooth. If dry, the
usually positive accounted for:  after 6-8 weeks pulp sensibility infection
fragment should be rehydrated by
testing
 No sensitivity to - If fragment is missing and soaking in water or saline for 20  after 1 year  Apical periodontitis.
percussion or palpation there are soft tissue minutes before bonding  Good quality
 If there is an associated  Lack of further root
injuries, radiographs of restoration
 Evaluate the tooth for a  Cover the exposed dentin with luxation, root fracture development in
the lip and/or cheek are Continued root
possible associated glass-ionomer or use a bonding or the suspicion of an immature teeth
A fracture confined to indicated to search for development in
luxation injury or root agent and composite resin associated luxation
enamel and dentin tooth fragments and/or immature teeth  Loss of restoration
fracture, especially if injury, the luxation
without pulp exposure foreign materials  If the exposed dentin is within
tenderness is present follow-up regimen  Breakdown of the
0.5mm of the pulp (pink but no restoration
 Recommended radiographs: prevails and should be
bleeding), place a calcium
used* Longer follow-
- One parallel periapical hydroxide lining and cover with a
ups will be needed
radiograph
material such as glass ionomer

- Additional radiographs
 Replace the temporary restoration
are indicated if signs or
with accepted dental restorative
symptoms of other
materials as soon as possible
potential injuries are
present

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Accepted Article

* = For crown fractured teeth with concomitant luxation injury, use the luxation follow-up schedule

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Accepted Article
Table 4 – Treatment guidelines for complicated crown fractures

COMPLICATED CROWN
FRACTURE Imaging, Radiographic
Clinical Findings Treatment Follow-Up Favorable Outcomes Unfavorable Outcomes
(Enamel-Dentin Fracture Assessment and Findings
with Pulp Exposure)

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 Normal mobility  Enamel-dentin loss is visible  In patients where teeth have Clinical and radiographic  Asymptomatic  Symptomatic
immature roots and open apices, it evaluations are
 No sensitivity to  Missing fragments should be  Positive response to  Discoloration
is very important to preserve the necessary:
percussion or palpation. accounted for: pulp sensibility
pulp. Partial pulpotomy or pulp  Pulp necrosis and
 after 6-8 weeks testing
 Evaluate the tooth for a - If fragment is missing and capping are recommended in order infection
possible associated there are soft tissue to promote further root  after 3 months  Good quality
 Apical periodontitis
luxation injury or root injuries, radiographs of development restoration
 after 6 months
fracture, especially if the lip and/or cheek are  Lack of further root
 Conservative pulp treatment (e.g.  Continued root
tenderness is present indicated to search for  after 1 year development in
partial pulpotomy) is also the development in
A fracture confined to tooth fragments and/or immature teeth
 Exposed pulp is sensitive  If there is an associated immature teeth
enamel and dentin with preferred treatment in teeth with
foreign debris luxation, root fracture  Loss of restoration
to stimuli (e.g. air, cold, completed root development
pulp exposure
sweets)  Recommended radiographs: or the suspicion of an
 Breakdown of the
 Non-setting calcium hydroxide or associated luxation
- One parallel periapical restoration
non-staining calcium silicate injury, the luxation
radiograph cements are suitable materials to be follow-up regimen
- Additional radiographs placed on the pulp wound prevails and should be
are indicated if signs or used* Longer follow-
 If a post is required for crown
symptoms of other ups will be needed
retention in a mature tooth with
potential injuries are
complete root formation, root canal
present
treatment is the preferred
treatment

 If the tooth fragment is available, it

can be bonded back on to the tooth
after rehydration and the exposed
pulp is treated

 In the absence of an intact crown

fragment for bonding, cover the

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Accepted Article
exposed dentin with glass-ionomer
or use a bonding agent and
composite resin

 Replace the temporary restoration

with accepted dental restorative
materials as soon as possible

* = For crown fractured teeth with concomitant luxation injury, use the luxation follow-up schedule

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Accepted Article
Table 5 – Treatment guidelines for uncomplicated crown-root fractures

UNCOMPLICATED CROWN-
ROOT FRACTURE
Imaging, Radiographic
(Crown-Root Fracture Clinical Findings Treatment Follow-Up Favorable Outcomes Unfavorable Outcomes
Assessment and Findings
Without Pulp Exposure)

 Pulp sensibility tests  Apical extension of fracture  Until a treatment plan is finalized, Clinical and radiographic  Asymptomatic  Symptomatic
usually positive usually not visible temporary stabilization of the loose evaluations are
 Positive response to  Discoloration
fragment to the adjacent tooth/teeth necessary:
 Tender to percussion.  Missing fragments should pulp sensibility
or to the non-mobile fragment should  Pulp necrosis and
be accounted for:  after 1 week testing
 Coronal, or mesial or be attempted infection
distal, fragment is usually - If fragment is missing  after 6-8 weeks  Continued root
 If the pulp is not exposed, removal of  Apical periodontitis
present and mobile and there are soft tissue development in
the coronal or mobile fragment and  after 3 months
injuries, radiographs of immature teeth  Lack of further root
 The extent of the fracture subsequent restoration should be
A fracture involving enamel, the lip and/or cheek are  after 6 months development in
(sub- or supra-alveolar) considered  Good quality
dentin and cementum indicated to search for immature teeth
should be evaluated  after 1 year restoration
(Note: Crown-root fractures tooth fragments or  Cover the exposed dentin with glass-  Loss of restoration
 then yearly for at least
typically extend below the foreign debris ionomer or use a bonding agent and
gingival margin)
5 years  Breakdown of the
composite resin
 Recommended radiographs: restoration

- One parallel periapical  Marginal bone loss

radiograph Future Treatment Options: and periodontal

- Two additional  The treatment plan is dependent, in inflammation

radiographs of the tooth part, on the patient’s age and

taken with different anticipated co-operation. Options
vertical and/or include:
horizontal angulations
 Orthodontic extrusion of the apical or

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Accepted Article
- Occlusal radiograph non-mobile fragment, followed by
restoration (may also need
 CBCT can be considered for
periodontal re-contouring surgery
better visualization of the
after extrusion)
fracture path, its extent,
and its relationship to the  Surgical extrusion
marginal bone; also, useful
 Root canal treatment and restoration
to evaluate the crown-root
if the pulp becomes necrotic and
ratio and to help determine
infected
treatment options
 Root submergence

 Intentional replantation with or

without rotation of the root

 Extraction

 Autotransplantation

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Accepted Article
Table 6 – Treatment guidelines for complicated crown-root fractures

COMPLICATED CROWN-
ROOT FRACTURE
Imaging, Radiographic
(Crown-Root Fracture Clinical Findings Treatment Follow-Up Favorable Outcomes Unfavorable Outcomes
Assessment and Findings
With Pulp Exposure)

 Pulp sensibility tests  Apical extension of fracture  Until a treatment plan is finalized, Clinical and radiographic  Asymptomatic  Symptomatic
usually positive usually not visible temporary stabilization of the loose evaluations are
 Continued root  Pulp necrosis and
fragment to the adjacent tooth/teeth or to necessary:
 Tender to percussion.  Missing fragments should be development in infection
the non-mobile fragment should be
accounted for:  after 1 week immature teeth
 Coronal, or mesial or attempted  Apical periodontitis
distal, fragment is - If fragment is missing and  after 6-8 weeks  Good quality
 In immature teeth with incomplete root  Lack of further root
usually present and there are soft tissue restoration
formation, it is advantageous to preserve  after 3 months development in
mobile injuries, radiographs of
the pulp by performing a partial immature teeth
the lip and/or cheek are  after 6 months
 The extent of the pulpotomy. Rubber dam isolation is
indicated to search for  Loss of restoration
fracture (sub- or  after 1 year
challenging but should be tried.
tooth fragments or  Breakdown of the
A fracture involving enamel, supra-alveolar)  then yearly for at least
foreign debris - Non-setting calcium hydroxide or restoration
dentin, cementum and the should be evaluated 5 years
non-staining calcium silicate
pulp  Recommended radiographs:  Marginal bone loss and
cements are suitable materials to be
(Note: Crown-root fractures - One parallel periapical periodontal
placed on the pulp wound
typically extend below the radiograph inflammation
gingival margin)  In mature teeth with complete root
- Two additional
formation, removal of the pulp is usually
radiographs of the tooth indicated
taken with different

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Accepted Article
vertical and/or horizontal - Cover the exposed dentin with glass-
angulations ionomer or use a bonding agent and
composite resin
- Occlusal radiograph
Future Treatment Options:
 CBCT can be considered for
better visualization of the  The treatment plan is dependent, in part,
fracture path, its extent, and on the patient’s age and anticipated co-
its relationship to the operation. Options include:
marginal bone; also useful to
 Completion of root canal treatment and
evaluate the crown-root
restoration
ratio and to help determine
treatment options  Orthodontic extrusion of the apical
segment (may also need periodontal re-
contouring surgery after extrusion)

 Surgical extrusion

 Root submergence

 Intentional replantation with or without

rotation of the root

 Extraction

 Autotransplantation

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Accepted Article
Table 7 – Treatment guidelines for root fractures

Imaging, Radiographic
ROOT FRACTURE Clinical Findings Treatment Follow up Favorable Outcomes Unfavorable Outcomes
Assessment and Findings

 The coronal segment  The fracture may be  If displaced, the coronal fragment should be Clinical and radiographic  Positive response  Symptomatic
may be mobile and may located at any level of the repositioned as soon as possible. evaluations are necessary: to pulp sensibility
 Extrusion and/or
be displaced root + testing; however, a
A  Check repositioning radiographically  after 4 weeks S excessive mobility of
false negative
 The tooth may be  Recommended the coronal segment
 Stabilize the mobile coronal segment with a passive  after 6-8 weeks response is
tender to percussion radiographs:
and flexible splint for 4 weeks. If the fracture is ++ possible for several  Radiolucency at the
 after 4 months S
fracture of the root  Bleeding from the - One parallel periapical located cervically, stabilization for a longer period of fracture line
months.
involving dentin, pulp and gingival sulcus may be radiograph time (up to 4 months) may be needed  after 6 months
Endodontic  Pulp necrosis and
cementum. seen
- Two additional  Cervical fractures have the potential to heal. Thus,  after 1 year treatment should infection with
The fracture may be
 Pulp sensibility testing radiographs of the the coronal fragment, especially if not mobile, not be started inflammation in the
 then yearly for at least 5
horizontal, oblique or a
may be negative tooth taken with should not be removed at the emergency visit solely on the basis fracture line
years
combination of both.
initially, indicating different vertical of no response to
 No endodontic treatment should be started at the
transient or permanent and/or horizontal pulp sensibility
emergency visit
neural damage angulations testing
 It is advisable to monitor healing of the fracture for
- Occlusal radiograph  Signs of repair
at least one year. Pulp status should also be
between the
 Root fractures may be monitored
fractured
undetected without
 Pulp necrosis and infection may develop later. It segments
additional imaging
usually occurs in the coronal fragment only. Hence,
 Normal or slightly
 In cases where the above endodontic treatment of the coronal segment only
more than
radiographs provide will be indicated. As root fracture lines are
physiological
insufficient information for

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Accepted Article
treatment planning, CBCT frequently oblique, determination of root canal mobility of the
can be considered to length may be challenging. An apexification coronal fragment
determine the location, approach may be needed. The apical segment rarely
extent and direction of the undergoes pathological changes that require
fracture treatment

 In mature teeth where the cervical fracture line is

located above the alveolar crest and the coronal
fragment is very mobile, removal of the coronal
fragment, followed by root canal treatment and
restoration with a post-retained crown will likely be
required. Additional procedures such as orthodontic
extrusion of the apical segment, crown lengthening
surgery, surgical extrusion or even extraction may be
required as future treatment options (similar to
those for crown-root fractures outlined above).

+ ++
S = splint removal (for mid-root and apical third fractures); S = splint removal (for cervical third fractures)

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Accepted Article
Table 8 – Treatment guidelines for alveolar fractures

Imaging, Radiographic
ALVEOLAR FRACTURE Clinical Findings Treatment Follow up Favorable Outcomes Unfavorable Outcomes
Assessment and Findings

 The alveolar fracture is  Fracture lines may be  Reposition any displaced segment Clinical and radiographic  Positive response  Symptomatic
The
complete and extends located at any level, from evaluations are necessary: to pulp sensibility
 Stabilize the segment by splinting the teeth with a  Pulp necrosis and
all the way from the the marginal bone to the + testing. (A false
passive and flexible splint for 4 weeks  after 4 weeks S infection
buccal to the palatal root apex negative response
bone in the maxilla and  Suture gingival lacerations if present  after 6-8 weeks is possible for  Apical periodontitis
 Recommended
from the buccal to the  Root canal treatment is contraindicated at the  after 4 months several months)  Inadequate soft
fracture involves the radiographs:
lingual bony surface in emergency visit tissue healing
alveolar bone and may  after 6 months  No signs of pulp
the mandible - One parallel periapical
extend to adjacent bones.  Monitor the pulp condition of all teeth involved, necrosis and  Non-healing of the
radiograph  after 1 year
 Segment mobility and both initially and at follow-ups, to determine if or infection bone fracture
displacement with - Two additional  then yearly for at least 5
when endodontic treatment becomes necessary  Soft tissue healing
radiographs of the  External
several teeth moving years
tooth taken with  Radiographic signs inflammatory
together are common
Bone and soft tissue
different vertical of bone repair (infection-related)
findings
healing must also be resorption
and/or horizontal
 Occlusal disturbances monitored  Slight tenderness
angulations
due to displacement of the bone to
- Occlusal radiograph palpation may
and misalignment of the
remain at the
fractured alveolar  In cases where the above
segment are often seen fracture line
radiographs provide
and/or on
insufficient information for
 Teeth in the fractured

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Accepted Article
segment may not treatment planning, a mastication for
respond to pulp panoramic radiograph several months
sensibility testing and/or CBCT can be
considered to determine
the location, extent and
direction of the fracture

+
S = splint removal

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Accepted Article
Table 9 – Treatment guidelines for concussion injuries of the teeth

Imaging, Radiographic
CONCUSSION Clinical Findings Treatment Follow-Up Favorable Outcome Unfavorable Outcome
Assessment and Findings

 Normal mobility  No radiographic  No treatment is needed. Clinical and radiographic  Asymptomatic  Symptomatic
abnormalities evaluations are
 The tooth is tender to  Monitor pulp condition for at  Positive response to pulp  Pulp necrosis and
necessary:
percussion and touch  Recommended least one year, but preferably sensibility testing; infection
radiographs: longer  after 4 weeks however, a false negative
 The tooth will likely  Apical periodontitis
response is possible for
respond to pulp - One parallel periapical  after 1 year
several months.  No further root
sensibility testing radiograph
Endodontic treatment development in
- Additional radiographs immature teeth
should not be started
An injury to the tooth- are indicated if signs solely on the basis of no
supporting structures or symptoms of other response to pulp
without abnormal potential injuries are
sensibility testing
loosening or present
 Continued root
displacement of the
development in
tooth, but with marked
immature teeth
tenderness to
percussion  Intact lamina dura

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Accepted Article
Table 10 – Treatment guidelines for subluxation injuries of the teeth

Imaging, Radiographic
SUBLUXATION Clinical Findings Treatment Follow-Up Favorable Outcome Unfavorable Outcome
Assessment and Findings

 The tooth is tender to  Radiographic appearance  Normally no treatment is Clinical and radiographic  Asymptomatic  Symptomatic
touch or light tapping is usually normal needed evaluations are
 Positive response to pulp  Pulp necrosis and
necessary:
 Tooth has increased  Recommended  A passive and flexible splint to sensibility testing; infection
+
mobility but is not radiographs: stabilize the tooth for up to 2  after 2 weeks S however, a false negative
 Apical periodontitis
displaced weeks may be used but only if response is possible for
- One parallel  after 12 weeks
there is excessive mobility or several months.  No further root
 Bleeding from the periapical radiograph
tenderness when biting on the  after 6 months Endodontic treatment development in
gingival crevice may be
- Two additional tooth should not be started immature teeth
present  after 1 year
radiographs of the
An injury to the tooth- solely on the basis of no  External inflammatory
 Monitor the pulp condition for
 The tooth may not tooth taken with response to pulp
supporting structures at least one year, but (infection-related)
respond to pulp different vertical sensibility testing
with abnormal preferably longer resorption – if this type
sensibility testing and/or horizontal
loosening, but without  Continued root of resorption develops,
initially indicating angulations
displacement of the development in root canal treatment
transient pulp damage.
tooth - Occlusal radiograph should be initiated
immature teeth
immediately, with the
 Intact lamina dura
use of a
corticosteroid/antibiotic
medicament initially,

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Accepted Article
which is then followed
by calcium hydroxide.
Alternatively, calcium
hydroxide can be used
as the sole intra-canal
medicament

+
S = splint removal

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Accepted Article
Table 11 – Treatment guidelines for extrusive luxation injuries of the teeth

Imaging, Radiographic
EXTRUSIVE LUXATION Clinical Findings Treatment Follow-Up Favorable Outcome Unfavorable Outcome
Assessment and Findings

 The tooth appears  Increased periodontal  Reposition the tooth by gently pushing It Clinical and radiographic  Asymptomatic  Symptomatic
elongated ligament space both back into the tooth socket under local evaluations are necessary:
 Clinical and  Pulp necrosis and
apically and laterally anesthesia +
 The tooth has  after 2 weeks S radiographic signs of infection
increased mobility  Tooth will not be seated  Stabilize the tooth for 2 weeks using a normal or healed
 after 4 weeks  Apical periodontitis
in its socket and will passive and flexible splint. If periodontium.
 The tooth will appear
appear elongated breakdown/fracture of the marginal  after 8 weeks  Breakdown of marginal
elongated incisally  Positive response to
incisally bone, splint for an additional 4 weeks bone
 after 12 weeks pulp sensibility
 Likely to have no
Displacement of the  Recommended  Monitor the pulp condition with pulp testing; however, a  External inflammatory
response to pulp  after 6 months
tooth out of its socket radiographs: sensibility tests false negative (infection-related)
sensibility tests  after 1 year
in an incisal/axial response is possible resorption – if this type
- One parallel  If the pulp becomes necrotic and
direction  then yearly for at least 5 for several months. of resorption develops,
periapical radiograph infected, endodontic treatment
years Endodontic root canal treatment
appropriate to the tooth’s stage of root
- Two additional should be initiated
treatment should not
development is indicated
radiographs of the be started solely on immediately, with the
tooth taken with Patients (and parents, where use of a
the basis of no
different vertical relevant) should be informed corticosteroid/antibiotic
response to pulp
and/or horizontal to watch for any unfavorable medicament initially,
sensibility testing
angulations outcomes and the need to which is then followed

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Accepted Article
- Occlusal radiograph return to clinic if they  No marginal bone by calcium hydroxide.
observe any loss Alternatively, calcium
hydroxide can be used
 Where unfavorable  Continued root
as the sole intra-canal
outcomes are identified, development in
medicament
treatment is often immature teeth
required. This is outside
the scope of these
guidelines. Referral to a
dentist with the relevant
expertise, training and
experience is advised

+
S = splint removal

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Accepted Article
Table 12 – Treatment guidelines for lateral luxation injuries of the teeth

Imaging, Radiographic Unfavorable

LATERAL LUXATION Clinical Findings Treatment Follow-Up Favorable Outcome
Assessment and Findings Outcome

 The tooth is displaced,  A widened periodontal  Reposition the tooth digitally by disengaging it Clinical and radiographic  Asymptomatic  Symptomatic
usually in a ligament space which is from its locked position and gently reposition it evaluations are
 Clinical and  Breakdown of
palatal/lingual or labial best seen on into its original location under local anesthesia. necessary:
radiographic signs marginal bone
direction radiographs taken with
- Method: Palpate the gingiva to feel the apex  after 2 weeks of normal or healed
horizontal angle shifts  Pulp necrosis and
 There is usually an of the tooth. Use one finger to push + periodontium
or occlusal exposures  after 4 weeks S infection
associated fracture of downwards over the apical end of the tooth,
 Positive response
the alveolar bone  Recommended then use another finger or thumb to push  after 8 weeks  Apical periodontitis
Displacement of the to pulp sensibility
tooth in any lateral radiographs: the tooth back into its socket  after 12 weeks  Ankylosis
 The tooth is frequently testing; however, a
direction, usually immobile as the apex - One parallel  Stabilize the tooth for 4 weeks using a passive false negative
 after 6 months  External
associated with a of the root is “locked” periapical and flexible splint. If breakdown/fracture of the response is replacement
 after 1 year
fracture or in by the bone fracture radiograph marginal bone or alveolar socket wall, splint for possible for several resorption
compression of the an additional 4 weeks  then yearly for at least months.
 Percussion will give a - Two additional  External
alveolar socket wall or 5 years Endodontic
high metallic radiographs of the  Monitor the pulp condition with pulp sensibility inflammatory
facial cortical bone treatment should
(ankylotic) sound tooth taken with tests at the follow-up appointments (infection-related)
not be started
different vertical resorption
 Likely to have no  At about 2 weeks post-injury, make an Patients (and parents,
solely on the basis
and/or horizontal
response to pulp endodontic evaluation: where relevant) should
of no response to
angulations
sensibility tests be informed to watch for
 Teeth with incomplete root formation: pulp sensibility
- Occlusal any unfavorable
testing
radiograph - Spontaneous revascularization may occur. outcomes and the need

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- If the pulp becomes necrotic and there are to return to clinic if they  Marginal bone
signs of inflammatory (infection-related) observe any height corresponds
external resorption, root canal treatment to that seen
 Where unfavorable
should be started as soon as possible. radiographically
outcomes are
after repositioning
- Endodontic procedures suitable for identified, treatment is
immature teeth should be used often required. This is  Continued root
outside the scope of development in
 Teeth with complete root formation:
these guidelines. immature teeth
- The pulp will likely become necrotic.
Referral to a dentist
- Root canal treatment should be started, with the relevant
using a corticosteroid-antibiotic or calcium expertise, training and
hydroxide as an intracanal medicament to
experience is advised
prevent the development of inflammatory
(infection-related) external resorption

+
S = splint removal

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Table 13 – Treatment guidelines for intrusive luxation injuries of the teeth

Imaging, Radiographic
INTRUSIVE LUXATION Clinical Findings Treatment Follow-Up Favorable Outcome Unfavorable
Assessment and Findings

 The tooth is displaced  The periodontal ligament Teeth with incomplete root formation Clinical and radiographic  Asymptomatic  Symptomatic
axially into the alveolar space may not be visible (immature teeth): evaluations are
 Tooth in place or is  Tooth locked in
bone for all or part of the root necessary:
 Allow re-eruption without intervention re-erupting place/ankylotic tone to
(especially apically)
 The tooth is immobile (spontaneous repositioning) for all intruded  after 2 weeks percussion
 Intact lamina dura
Displacement of the  The cemento-enamel teeth independent of the degree of intrusion +
 Percussion will give a  after 4 weeks S  Pulp necrosis and
junction is located more  Positive response to
tooth in an apical high metallic  If no re-eruption within 8 weeks, initiate infection
apically in the intruded  after 8 weeks pulp sensibility
direction into the (ankylotic) sound orthodontic repositioning
tooth than in adjacent testing; however, a  Apical periodontitis
alveolar bone  after 12 weeks
 Likely to have no non-injured teeth  Monitor the pulp condition false negative
 Ankylosis
response to pulp  after 6 months response is possible
 Recommended  In teeth with incomplete root formation
sensibility tests for several months.  External replacement
spontaneous pulp revascularization may  after 1 year
radiographs: resorption
Endodontic
occur. However, if it is noted that the pulp  then yearly for at least
- One parallel treatment should not  External inflammatory
becomes necrotic and infected or that there 5 years
periapical radiograph be started solely on (infection-related)
are signs of inflammatory (infection-related)
the basis of no resorption – if this type
- Two additional external resorption at follow-up
response to pulp of resorption develops,
radiographs of the appointments, root canal treatment is Patients (and parents,
where relevant) should sensibility testing root canal treatment
tooth taken with indicated and should be started as soon as
different vertical possible when the position of the tooth be informed to watch for  No signs of root should be initiated

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and/or horizontal allows. Endodontic procedures suitable for any unfavorable resorption immediately, with the
angulations immature teeth should be used. outcomes and the need use of a
 Continued root
to return to clinic if they corticosteroid/antibiotic
- Occlusal radiograph  Parents must be informed about the development in
observe any medicament initially,
necessity of follow-up visits. immature teeth
which is then followed
 Where unfavorable
Teeth with complete root formation (mature by calcium hydroxide.
outcomes are
teeth): Alternatively, calcium
identified, treatment is
 Allow re-eruption without intervention if the hydroxide can be used
often required. This is
tooth is intruded less than 3mm. If no re- as the sole intra-canal
outside the scope of
eruption within 8 weeks, reposition medicament
these guidelines.
surgically and splint for 2 weeks. Referral to a dentist
Alternatively, reposition orthodontically with the relevant
before ankylosis develops expertise, training and

 If the tooth is intruded 3-7 mm, reposition experience is advised

surgically (preferably) or orthodontically

 If the tooth is intruded beyond 7mm,

reposition surgically

 In teeth with complete root formation, the

pulp almost always becomes necrotic. Root
canal treatment should be started at 2
weeks or as soon as the position of the tooth
allows, using a corticosteroid-antibiotic or
calcium hydroxide as an intra canal
medication. The purpose of this treatment is
to prevent the development of inflammatory
(infection-related) external resorption

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+
S = splint removal

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