Despite the many journal articles and reviews that
have been published regarding the treatment of
trauma to teeth, the endodontic management of
these injuries is often still not fully understood. The
purpose of this review is to establish clear and
up-to-date guidelines for practitioners who are faced with
treating dental injuries on a day-to-day basis, based
on an assessment of current available scientific
information relating to the endodontic management
of these injuries.
Treatment is discussed under the headings:
infractions, uncomplicated crown fractures,
complicated crown fractures, crown-root fractures,
root fractures, luxation injuries, avulsion, root
resorption, pulp canal obliteration and open-apex
teeth. Emphasis is placed on the treatment of
traumatized immature teeth where maintenance of
pulp blood supply is important to encourage
continued development of the root system. Only the
treatment of traumatized permanent anterior teeth is
reviewed.
Information contained in this article is based on a
review of the literature on dental trauma which
involved a MEDLINE search using the key words
“dental trauma” and the individual topics listed
above. The guidelines produced by the International
Association of Dental Traumatology, the American
Academy of Pediatric Dentistry and the American
Association of Endodontists were also reviewed and
the recommendations contained in this paper are in
concert with the major recommendations of these
bodies.
The management of patients who have suffered
traumatic injuries to their dentition is an integral part
of general dental practice. This will continue to be the
case given the ever-increasing incidence of dental
trauma as a result of traffic accidents, sporting injuries,
risk-taking physical activities, violence and child
physical abuse in modern society.
There are already
*Specialist Endodontist, Brisbane, Queensland.
†Private General Dental Practitioner, Yeppoon, Queensland.
Australian Dental Journal Supplement 2007;52:(1 Suppl):S122-S137
numerous texts and articles which discuss the causes
and incidence of dental trauma.
It is not the purpose
of this review to consider these aspects of dental
trauma; instead, the immediate and long-term
endodontic management of traumatized teeth is the
focus of this review. It would be remiss not to state,
however, that all clinicians must be cognizant of the
fact that some dental injuries to children may be a
result of child abuse, and there is a need to be vigilant
in assessing an injured child and the circumstances of
an injury to distinguish, where possible, between
accidental injuries and injuries from abuse.
Dental injuries often involve damage not only to the
tooth, but also to the supporting tissues. If treatment is
to be completely successful, an examination of a patient
with dental injuries must pay attention to both
components jointly. Soft tissue injuries should be
assessed; displaced or lacerated tissues should be
immediately repositioned and where necessary sutured
into place.
Where soft tissue injuries occur
concomitantly with tooth fractures, the soft tissues
should be examined for the presence of embedded tooth
fragments.
A number of studies have confirmed that fracture of
the tooth results in disruption of the energy of the blow
and minimizes damage to the periapical region.
Tooth mobility is more often associated with teeth without
hard tissue damage than with teeth that are fractured.
Prognosis is better in teeth with hard tissue damage
than in teeth that are luxated.
Where the supporting
tissues are concurrently damaged, the prognosis for the
tooth, particularly with respect to the vitality of the
pulp, is poorer.
Thus, teeth that are not obviously
traumatized may be the ones that could present long-term
management problems.
No review on the management of dental traumatic
injuries would be complete without a discussion of the
need to fully assess a patient with dental injuries:
assessing the injured dental hard and soft tissues,
injuries to supporting tissues and to the patient as a
whole. The systematic assessment of a patient with
traumatic dental injuries is well covered in the
literature.
Many strategies have been suggested for
the prevention of traumatic dental injury and there is
considerable evidence to support the efficacy of these
preventive aspects pertaining to dental injuries.
Splinting of teeth with luxation injuries, avulsions
and root fractures is often necessary to stabilize a tooth
in position, and to assist in periodontal and pulpal
healing. A flexible splint has been shown to be the most
desirable.
The American Academy of Pediatric
Dentistry suggests that an ideal splint should amongst
other things: be easily fabricated in the mouth without
additional trauma; be passive, unless orthodontic forces
are intended; allow physiological mobility;
be non-irritating to soft tissues; not interfere with the
occlusion; allow endodontic access; be easily cleaned
and easily removed.
Recommended splinting times are
up to two weeks for most avulsion and luxation injuries
unless they occur in association with alveolar fractures,
up to four weeks for lateral luxation injuries, alveolar
fractures and root fractures, and up to four months for
cervical-third root fractures.
Many dental injuries do not occur singly.
Thus, these splinting times cannot be
rigorously applied. In general, splinting times have to
be adjusted to accommodate the more major injuries.
All traumatic dental injuries need to be followed up
over time. Follow-up procedures include a clinical
examination, a radiographic assessment and pulp
sensibility testing. Recommendations for follow-up
examinations for injuries proposed in this study are in
accord with those recommended by the International
Association of Dental Traumatology.
While continued negative responses to pulp testing
procedures imply that a pulp has become necrotic, pulp
sensibility testing procedures test only a neural
response. Blood vessels and nerves differ in their
elasticity. Thus, it is possible to disrupt the nerve supply
to a tooth without disrupting blood supply. Also, it is
possible for a pulp to revascularize without there being
a concomitant neural regeneration. Hence, the absence
of a positive result to pulp sensibility testing does not
automatically imply loss of vitality of pulpal tissues.
Careful attention must be placed on clinical assessment
and an examination of changes that occur both within
the pulp canal and at the apex. If calcification continues
to occur, the pulp must be regarded as vital even if the
response to pulp sensibility testing is negative or
ambiguous.
Recommendations for the overall management of
dental trauma have been produced by the International
Association of Dental Traumatology and the American
Academy of Pediatric Dentistry,
and in a number of
texts and articles.
This paper specifically reviews
only the endodontic management of traumatized
permanent anterior teeth. The role of endodontic
treatment following trauma to these teeth has been
reviewed in the past.
In this study, the endodontic
management of teeth that have been traumatized is
discussed in light of recent developments and guidelines
for their endodontic management are described. In the
past, variations in classification techniques, clinical
assessment procedures, observation times,
and short-comings in the statistical assessment of data have all
clouded the issue. More recently, however, thanks to
the rigid methodology proposed by Andreasen and his
many co-workers,
many of these variations have been
eliminated from the literature. The classification of
dental injuries described by Andreasen is, in general,
followed.
Splinting of teeth with luxation injuries, avulsions
and root fractures is often necessary to stabilize a tooth
in position, and to assist in periodontal and pulpal
healing. A flexible splint has been shown to be the most
desirable.
The American Academy of Pediatric
Dentistry suggests that an ideal splint should amongst
other things: be easily fabricated in the mouth without
additional trauma; be passive, unless orthodontic forces
are intended; allow physiological mobility;
be non-irritating to soft tissues; not interfere with the
occlusion; allow endodontic access; be easily cleaned
and easily removed.
Recommended splinting times are
up to two weeks for most avulsion and luxation injuries
unless they occur in association with alveolar fractures,
up to four weeks for lateral luxation injuries, alveolar
fractures and root fractures, and up to four months for
cervical-third root fractures.
Many dental injuries do not occur singly.
Thus, these splinting times cannot be
rigorously applied. In general, splinting times have to
be adjusted to accommodate the more major injuries.
All traumatic dental injuries need to be followed up
over time. Follow-up procedures include a clinical
examination, a radiographic assessment and pulp
sensibility testing. Recommendations for follow-up
examinations for injuries proposed in this study are in
accord with those recommended by the International
Association of Dental Traumatology.
While continued negative responses to pulp testing
procedures imply that a pulp has become necrotic, pulp
sensibility testing procedures test only a neural
response. Blood vessels and nerves differ in their
elasticity. Thus, it is possible to disrupt the nerve supply
to a tooth without disrupting blood supply. Also, it is
possible for a pulp to revascularize without there being
a concomitant neural regeneration. Hence, the absence
of a positive result to pulp sensibility testing does not
automatically imply loss of vitality of pulpal tissues.
Careful attention must be placed on clinical assessment
and an examination of changes that occur both within
the pulp canal and at the apex. If calcification continues
to occur, the pulp must be regarded as vital even if the
response to pulp sensibility testing is negative or
ambiguous.
Recommendations for the overall management of
dental trauma have been produced by the International
Association of Dental Traumatology and the American
Academy of Pediatric Dentistry,
and in a number of
texts and articles.
This paper specifically reviews
only the endodontic management of traumatized
permanent anterior teeth. The role of endodontic
treatment following trauma to these teeth has been
reviewed in the past.
In this study, the endodontic
management of teeth that have been traumatized is
discussed in light of recent developments and guidelines
for their endodontic management are described. In the
past, variations in classification techniques, clinical
assessment procedures, observation times,
and short-comings in the statistical assessment of data have all
clouded the issue. More recently, however, thanks to
the rigid methodology proposed by Andreasen and his
many co-workers,
many of these variations have been
eliminated from the literature. The classification of
dental injuries described by Andreasen is, in general,
followed.