Contents
Epidemiology of Traumatic Dental Injuries
TRAUMA PREVALENCE
TRAUMA PREVALENCE IN 5-YEAR-OLD CHILDREN
TRAUMA PREVALENCE IN 12-YEAR-OLD CHILDREN
TRAUMA PREVALENCE AND INCIDENCES IN THE PRIMARY DENTITION
TRAUMA PREVALENCE AND INCIDENCES IN THE PERMANENT DENTITION
ETIOLOGY OF TRAUMA
ETIOLOGY OF TRAUMA IN VARIOUS AGE GROUPS
Pathophysiology and Consequences of Dental Trauma
PATHOPHYSIOLOGY OF TRAUMA: SEPARATION INJURY
PATHOPHYSIOLOGY OF TRAUMA: CRUSHING INJURY
EARLY WOUND HEALING EVENTS
LATER WOUND HEALING EVENTS
REPAIR-RELATED (SURFACE) RESORPTION
INFECTION-RELATED (INFLAMMATORY) RESORPTION
ANKYLOSIS-RELATED (REPLACEMENT) RESORPTION
TRANSIENT MARGINAL AND APICAL BREAKDOWN OF BONE
PERMANENT MARGINAL BREAKDOWN
EFFECT OF TREATMENT ON WOUND HEALING AFTER LUXATION AND REPLANTATION AFTER AVULSION
EFFECT OF REPOSITIONING
EFFECT OF SPLINTING
EFFECT OF ANTIBIOTICS
NOTES
Classification of Dental Injuries
INJURIES TO THE HARD DENTAL TISSUES AND THE PULP
INJURIES TO THE HARD DENTAL TISSUES: THE PULP, PERIODONTAL LIGAMENT AND ALVEOLAR PROCESS
INJURIES TO THE SUPPORTING TISSUES
INJURIES TO THE SUPPORTING TISSUES
INJURIES TO GINGIVA, ORAL MUCOSA OR SKIN
Examination and Diagnosis
CLINICAL EXAMINATION
MOBILITY TEST
PERCUSSION TEST
PULPAL SENSIBILITY TESTING
RADIOGRAPHIC EXAMINATION
RADIOGRAPHIC EXAMINATION OF SOFT TISSUE INJURIES
FOLLOW-UP
NOTES
Diagnosis of Pulpal Healing Complications
PULP HEALING
PULP NECROSIS
PULP CANAL OBLITERATION
TRANSIENT APICAL BREAKDOWN
Diagnosis of Periodontal Healing Complications
REPAIR-RELATED RESORPTION (SURFACE RESORPTION)
INFECTION-RELATED RESORPTION (INFLAMMATORY RESORPTION)
ANKYLOSIS-RELATED RESORPTION (REPLACEMENT RESORPTION)
TRANSIENT MARGINAL BREAKDOWN
Treatment Priorities after Dental Trauma
ACUTE TREATMENT PRIORITY
SUBACUTE TREATMENT PRIORITY
DELAYED TREATMENT PRIORITY
Crown Fracture without Pulp Exposure
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES
TREATMENT AND POSTOPERATIVE CONTROL
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
Crown Fracture with Pulp Exposure
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS
TREATMENT
PULP CAPPING
PARTIAL PULPOTOMY
EXPECTED OUTCOME: PULP CAPPING
EXPECTED OUTCOME: PARTIAL PULPOTOMY
Crown-Root Fracture
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS
TREATMENT PRINCIPLES
FRAGMENT REMOVAL AND GINGIVAL REATTACHMENT (FIGURE A)
FRAGMENT REMOVAL AND SURGICAL EXPOSURE OF SUBGINGIVAL FRACTURE (FIGURE B)
FRAGMENT REMOVAL AND ORTHODONTIC EXTRUSION (FIGURE C)
FRAGMENT REMOVAL AND SURGICAL EXTRUSION (FIGURE D)
PARTIAL OR TOTAL TOOTH REMOVAL
Root Fracture
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES
HEALING EVENTS AFTER ROOT FRACTURE
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
Alveolar Process Fracture
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES
TREATMENT
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
NOTES
Concussion
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS
TREATMENT
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
NOTES
Subluxation
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS
TREATMENT
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
NOTES
Extrusive Luxation
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES
TREATMENT
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
NOTES
Lateral Luxation
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES
TREATMENT
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
NOTES
Intrusive Luxation
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES
TREATMENT
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
Avulsion
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
BIOLOGICAL CONSIDERATIONS AND TREATMENT PRINCIPLES
FIRST AID FOR AVULSED TEETH
TREATMENT SCENARIOS
CLOSED APEX: TOOTH REPLANTED PRIOR TO THE PATIENT’S ARRIVAL AT THE CLINIC
CLOSED APEX: EXTRAORAL DRY TIME LESS THAN 60 MIN. THE TOOTH HAS BEEN KEPT IN PHYSIOLOGIC STORAGE MEDIA
CLOSED APEX: EXTRAORAL DRY TIME EXCEEDING 60 MIN. OR LONG STORAGE IN NON-PHYSIOLOGIC MEDIA
OPEN APEX: TOOTH REPLANTED PRIOR TO THE PATIENTS ARRIVAL AT THE CLINIC
OPEN APEX: EXTRAORAL DRY TIME LESS THAN 60 MIN. THE TOOTH HAS BEEN KEPT IN PHYSIOLOGIC STORAGE MEDIA
OPEN APEX: EXTRAORAL DRY TIME EXCEEDING 60 MIN. OR LONGER STORAGE IN NON-PHYSIOLOGIC MEDIA
ANTIBIOTICS
TETANUS PROPHYLAXIS
PATIENT INSTRUCTIONS
ENDODONTIC CONSIDERATIONS
TEETH WITH CLOSED APICES
TEETH WITH OPEN APICES
FOLLOW-UP
EXPECTED OUTCOME: PULP
EXPECTED OUTCOME: PDL
EXPECTED OUTCOME: PDL
NOTES
Injuries to the Primary Dentition
DESCRIPTION AND CLINICAL APPEARANCE
RADIOGRAPHIC APPEARANCE
RADIOGRAPHIC TECHNIQUE FOR DETERMINING INVASION OF THE FOLLICLE
BIOLOGICAL CONSIDERATIONS
TREATMENT PRINCIPLES
TREATMENT
FOLLOW-UP
EXPECTED OUTCOME
CONCUSSION
SUBLUXATION
EXTRUSION
LATERAL LUXATION
INTRUSION
AVULSION
FRACTURE OF THE ALVEOLAR PROCESS
Soft Tissue Injuries
DESCRIPTION AND CLINICAL APPEARANCE
ABRASION OF SKIN, MUCOSA AND GINGIVA
CONTUSION OF SKIN, MUCOSA AND GINGIVA
SUPERFICIAL LACERATION OF SKIN, MUCOSA OR GINGIVA
PENETRATING LIP WOUNDS
AVULSION OF SKIN, MUCOSA AND GINGIVA
TREATMENT PRINCIPLES FOR SOFT TISSUE WOUNDS
MECHANICAL MANIPULATION OF THE WOUND
ANTIBIOTICS AND TETANUS PROPHYLAXIS TREATMENT
ANTIBIOTIC PROPHYLAXIS
TETANUS PROPHYLAXIS
TREATMENT
ABRASIONS AND CONTUSIONS
NON-PENETRATING LACERATIONS
PENETRATING LACERATIONS OF THE LIP
SOFT TISSUE AVULSION
Splinting
ETCHING ENAMEL
RINSING AND DRYING ENAMEL
FLEXIBLE TEMPORIZATION MATERIAL SPLINT
FLEXIBLE WIRE/FIBER COMPOSITE SPLINT
REMOVING A TEMPORIZATION MATERIAL SPLINT
REMOVING A FLEXIBLE WIRE/FIBER COMPOSITE SPLINT
SPLINTING TIMES
Endodontic Considerations in Dental Trauma
PULP AND PERIODONTAL LIGAMENT PATHOSIS FOLLOWING DENTAL CARIES AND DENTAL TRAUMA
PROBLEMS OF PULP NECROSIS AND DEVELOPING ROOT FORMATION: TREATMENT OBJECTIVES
PROBLEMS WITH INFECTION-RELATED ROOT RESORPTION
PROBLEMS OF ANKYLOSIS-RELATED RESORPTION
TIME RELATION OF VARIOUS PROPERTIES OF CALCIUM HYDROXIDE
PULP NECROSIS WITH OR W ITHOUT INFECTION-RELATED RESORPTION: COMPLETED ROOT FORMATION
TREATMENT OF TRAUMATIC DENTAL INJURIES USING MINERAL TRIOXIDE AGGREGATE
PULP CAPPING AND PULPOTOMY
TREATMENT OF PULP NECROSIS IN IMMATURE TEETH
TREATMENT OF ROOT FRACTURES
NOTES
Decoronation of Ankylosed Teeth in Adolescents
PERIODONTAL LIGAMENT PATHOLOGY AND ITS ROLE IN TOOTH ERUPTION
IMPORTANT MARGINAL PERIODONTAL STRUCTURES INVOLVED IN INFRAOCCLUSION
BIOLOGICAL CONSIDERATIONS IN DECORONATION
HEALING EVENTS AFTER DECORONATION
CLINICAL CASE OF DECORONATION
Predictors for Healing Complications
PULPAL HEALING AND PULPAL NECROSIS
PDL HEALING AND ROOT RESORPTION
DISTURBED/ARRESTED ROOT DEVELOPMENT
PREDICTORS FOR ROOT RESORPTION
MARGINAL BONE HEALING AND BONE LOSS
TOOTH SURVIVAL AND TOOTH LOSS
USE OF PREDICTORS IN AN INTERACTIVE DENTAL TRAUMA GUIDE
PROGNOSIS ESTIMATION FOR INDIVIDUAL PATIENTS
NOTES
Tooth Survival in the Permanent Dentition
DESCRIPTION
CROWN FRACTURE
CONCUSSION AND SUBLUXATION
EXTRUSION
LATERAL LUXATION
INTRUSION
ROOT FRACTURE
ALVEOLAR FRACTURE
AVULSION AND REPLANTATION
Information for the Patient About Dental Trauma
PRIMARY (MILK) TOOTH INJURIES
FRACTURE OF PERMANENT TEETH
LOOSENED OR DISPLACED PERMANENT TEETH
FRACTURE OF THE JAW
DIET
ORAL HYGIENE
FOLLOW-UP EXAMINATION
PROGNOSIS OF TREATMENT
INJURY REPORT
INSURANCE
Information for the Public About Dental Trauma
DEVELOPING PUBLIC DENTAL TRAUMA AWARENESS
INTERNET USE IN TRAUMA EDUCATION AND PREVENTION
TRAUMA BROCHURES AND POSTERS
FIRST-AID AND TREATMENT OF TRAUMA TO PRIMARY TEETH
FIRST-AID AND TREATMENT OF TRAUMA TO PERMANENT TEETH
FIRST-AID FOR A CROWN FRACTURE
FIRST-AID FOR AN AVULSED PERMANENT TOOTH
Prevention of Traumatic Dental Injuries
MECHANISM OF MOUTHGUARD PROTECTION
DENTAL AND OTHER INJURIES RELATED TO VARIOUS SPORTS
VARIOUS TYPES OF MOUTH PROTECTORS
FACE MASKS
EFFECT OF MOUTHGUARDS AND FACE MASK PROTECTION IN AMERICAN FOOTBALL
EFFECT OF MOUTHGUARD PROTECTION IN ICE HOCKEY
EFFECT OF MOUTHGUARD PROTECTION IN BASKETBALL
EFFECT OF MOUTHGUARDS IN BOXING
EFFECT OF MOUTHGUARDS IN SOCCER
EFFECT OF HELMET PROTECTION IN BICYCLING
EFFECT OF HELMET PROTECTION IN MOTORCYCLE-RELATED INJURIES
EFFECT OF SAFETY BELTS IN MOTOR VEHICLE-RELATED INJURIES
EFFECT OF HELMET PROTECTION IN HORSEBACK RIDING
NOTES
Appendix 1
Appendix 2
Appendix 3
References
Index
EULA
This edition first published 2011
© 1999 Munksgaard
© 2003 Blackwell Munksgaard
© 2011 J.O. Andreasen, L.K. Bakland, M.T. Flores, F.M. Andreasen and L. Andersson
Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell.
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First edition published 1999
Second edition 2003
Third edition 2011
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Library of Congress Cataloging-in-Publication Data
Traumatic dental injuries: a manual / J.O. Andreasen ... [et al.]. – 3rd ed.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-9061-9 (pbk.: alk. paper) 1. Teeth–Wounds and injuries–Handbooks, manuals, etc. 2. Dentistry, Operative–Handbooks, manuals, etc. I. Andreasen, J. O.
[DNLM: 1. Tooth Injuries–diagnosis–Handbooks. 2. Tooth Injuries–therapy–Handbooks. WU 49]
RK501.5.T73 2011
617.6044–dc22
2010040958
A catalogue record for this book is available from the British Library.
Artwork by Henning Dalhoff Aps, Tue Frigaard Hansen from 360 Degree, Karina Nekes Suhr and Søren Ahrensburg Steno Christensen
Layout by Tue Frigaard Hansen from 360 Degree, Karina Nekes Suhr and Søren Ahrensburg Steno Christensen
1 2011
Preface to Third Edition
The third edition of Traumatic Dental Injuries – A Manual includes several new aspects of dental traumatology and an updating of existing material. The new sections that have been included describe soft tissue injuries associated with dental trauma, show how decoronation of ankylosed anterior teeth in adolescents can preserve the alveolar process for later implant placement or prosthodontic restoration and identify predictors for pulpal and periodontal ligament healing complications as well as for tooth loss. Furthermore the use of an internet - based interactive Dental Trauma Guide to predict healing complication for individual trauma scenarios is introduced. An added bonus is an enclosed DVD that shows animated treatment procedures for all trauma entities. 
J. O. Andreasen, L. K. Bakland, M. T. Flores, F. M. Andreasen, L. Andersson
Copenhagen, January 2011
Preface to Second Edition
In this second edition, the epidemiological section on global trauma frequencies has been updated and all chapters have been revised, especially with respect to the urgency of acute treatment. Furthermore, the chapter on prevention of oral injuries has been expanded. New chapters include diagnosis of pulp and periodontal healing complications, long-term prognosis of the various trauma entities, and information to the patient subsequent to emergency treatment. Finally, a chapter has been included which deals with the principles of endodontic treatment of traumatized teeth.
J. O. Andreasen, F. M. Andreasen, L. K. Bakland, M. T. Flores
Copenhagen, January 2003
Preface to First Edition
In Traumatic Dental Injuries – A Manual, we present the highlights of dental traumatology in a format which will be a ready reference for general practitioners and aid dental students in their studies. Each chapter is designed to describe the principles in the diagnosis and treatment of the specific traumatic dental injury, including treatment objectives, treatment parameters and long-term expectations based on existing long-term studies of various trauma entities. In order to standardize diagnostic and treatment procedures, examination forms and follow-up protocol are provided in the appendices. As no type of dental trauma is ‘perfect’, a given injury type has been generated electronically by a medical artist, in order to enhance similarities and differences between the various injury groups. Periodontal and pulpal healing for the given injuries are based on recent long-term follow-up studies.
Finally, information to the public is also presented. As the best treatment result follows prompt emergency care, informed individuals at the scene of the injury can aid the dental practitioner in optimizing treatment and hopefully in preventing injuries.
It is the authors’ hope that Traumatic Dental Injuries – A Manual will fill the gap in dental education and give dental trauma its full birthright.
J. O. Andreasen, F. M. Andreasen, L. K. Bakland, M. T. Flores
Copenhagen, January 1999
Contributors
Epidemiology of Traumatic Dental Injuries
OBJECTIVES
1 Recognize trauma incidence and prevalence in the primary and permanent dentitions.
2 Recognize peak incidences of trauma in relation to age and sex.
3 Recognize typical causes of trauma.
TRAUMA PREVALENCE
The prevalence (i.e. the number of injuries up to a given age) of traumatic dental injuries has been examined in many countries, usually reporting very high figures.1 It should, however, be noted that most of these studies represent prevalences in various age groups, and therefore these prevalences cannot be compared. When prevalences are specified for 5-and 12-year-olds, the figures can be seen in the maps below. Please note that only countries where reliable figures were available have been included and color-coded.
TRAUMA PREVALENCE IN 5-YEAR-OLD CHILDREN
In 5-year-old children, approximately one-third have suffered a traumatic dental injury involving primary teeth, most often tooth luxation; boys have a slightly higher frequency than girls.1,2
TRAUMA PREVALENCE IN 12-YEAR-OLD CHILDREN
In 12-year-old children, 20–30% of them have suffered dental injuries, with boys‘ injuries occurring approximately one-third more frequently than girls’. The typical injury is an uncomplicated crown fracture.1,2
TRAUMA PREVALENCE AND INCIDENCES IN THE PRIMARY DENTITION
Annual trauma incidences (i.e. the number of new injuries occurring during a year) peak in the primary dentition at 2–3 years of age, when motor coordination is developing and the children start moving around on their own.1,2
TRAUMA PREVALENCE AND INCIDENCES IN THE PERMANENT DENTITION
In the permanent dentition, peak incidence for boys is found at 9–10 years, during which time vigorous playing and sports activities become more frequent.1,2
Longitudinal studies during one year have shown incidences between 1.3 and 4% for school children and 0.4% for all ages in the population of a society.1
ETIOLOGY OF TRAUMA
The most common causes of injuries in the permanent dentition are falls, followed by traffic injuries, acts of violence and sports accidents.3
ETIOLOGY OF TRAUMA IN VARIOUS AGE GROUPS
In preschool children (0–6 years) the injuries mainly result from falling and usually occur in the home environment during day time.
In school children (7–15 years) the injuries mainly result from being pushed and hit, and from falling; these occur mainly in school or sports areas during day time.
In adolescents and adults the injuries mainly result from push/hit injuries which predominantly occur during leisure hours.4
