TRAUMATIC DENTAL INJURIES – A Manual Third Edition J. O. ANDREASEN L. K. BAKLAND M. T. FLORES F. M. ANDREASEN L. ANDERSSON 1 This edition fi rst 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 Scientifi c, Technical, and Medical business to form Wiley-Blackwell. 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If professional advice or other expert assistance is required, the services of a competent professional should be sought. 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 2 Preface to Third Edition The third edition of T raumatic 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- b ased 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 3 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 specifi c 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 diff erences between the various injury groups. Periodontal and pulpal healing for the given injuries are based on recent long - term follow- u p studies. F inally, 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. I t is the authors’ hope that T raumatic Dental Injuries – A Manual will fi ll 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 4 Contributors JENS O. ANDREASEN, DDS, ODONT DR. HC, FRCS Department of Oral and Maxillofacial Surgery University Hospital (Rigshospitalet) Copenhagen Denmark LEIF K. BAKLAND, DDS Diplomate, American Board of Endodontics Ronald E. Buell Professor of Endodontics School of Dentistry, Loma Linda University Loma Linda, California USA MARIA T. FLORES, DDS Professor of Pediatric Dentistry Faculty of Dentistry University of Valparaiso Valparaiso Chile FRANCES M. ANDREASEN, DDS, DR. ODONT Research Associate Department of Oral and Maxillofacial Surgery University Hospital (Rigshospitalet) Copenhagen Denmark LARS ANDERSSON, DDS, ODONT DR. Professor of Oral and Maxillofacial Surgery Faculty of Dentistry Kuwait University Kuwait City Kuwait 5 Contents Epidemiology of Traumatic Dental Injuries 8 Pathophysiology and Consequences of Dental Trauma 10 Classifi cation of Dental Injuries 16 Examination and Diagnosis 18 Diagnosis of Pulpal Healing Complications 22 Diagnosis of Periodontal Healing Complications 24 Treatment Priorities after Dental Trauma 26 Crown Fracture without Pulp Exposure 28 Crown Fracture with Pulp Exposure 30 Crown-Root Fracture 32 Root Fracture 34 Alveolar Process Fracture 36 Concussion 38 Subluxation 40 Extrusive Luxation 42 Lateral Luxation 44 Intrusive Luxation 46 Avulsion 48 Injuries to the Primary Dentition 54 Soft Tissue Injuries 58 Splinting 62 Endodontic Considerations in Dental Trauma 64 Decoronation of Ankylosed Teeth in Adolescents 68 Predictors for Healing Complications 70 Tooth Survival in the Permanent Dentition 74 Information for the Patient About Dental Trauma 76 Information for the Public About Dental Trauma 78 Prevention of Traumatic Dental Injuries 80 Appendices 84 References 88 Index 97 7 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 T he 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 fi gures. 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 specifi ed for 5 - and 12 - year - olds, the fi gures can be seen in the maps below. Please note that only countries where reliable fi gures were available have been included and color - coded. TRAUMA PREVALENCE IN 5 - YEAR - OLD CHILDREN In 5 - year - old children, approximately one - third have suff ered 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 suff ered dental injuries, with boys ’ injuries occurring approximately one - third more frequently than girls ’ . The typical injury is an uncomplicated crown fracture. 1 ,2 Traumatic Dental Injuries: A Manual, Third Edition © J.O. Andreasen, L.K. Bakland, M.T. Flores, F.M. Andreasen and L. Andersson Published 2011 by Blackwell Publishing Ltd 8