Traumatic Dental Injuries










9
Traumatic
Dental Injuries
The abilities to diagnose and properly treat traumat-
ic dental injuries are essential skills for the practicing
endodontist. A joint symposium in 2012 between the
American Association of Endodontists (AAE) and the
American Academy of Pediatric Dentistry resulted in
the release of a new set of guidelines on the diagnosis
and treatment of traumatic dental injuries. The Ameri-
can Board of Endodontics (ABE) exam requires intimate
knowledge of these guidelines in addition to general fa-
miliarity with the literature on which these guidelines are
based. A 2013 supplement in the Journal of Endodon-
tics was published with a specic focus on dental trauma
in conjunction with the release of these guidelines. This
chapter presents a review of traumatic dental injuries
and their management and will largely focus on the per-
manent dentition.
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178
Traumatic Dental Injuries
9
Epidemiology
Trauma to the orofacial region is a common nding in young patients, as reviewed by
Andersson (Fig 9-1). Five percent of all bodily injuries are to the orofacial region, and this
percentage increases substantially in preschool-aged children, where as many as 17% of
all bodily injuries are to the orofacial region. Population-based studies indicate that the
incidence of traumatic dental injuries is between 1% and 3%, and the prevalence is from
20% in the permanent dentition to 30% in the primary dentition. Of all patients seeking
treatment for injuries to the orofacial region, 92% have experienced dental trauma, 28%
have been affected by soft tissue injuries, and 6% have suffered jaw fractures. Injuries occur
most frequently during the rst 10 years of life and are rarely encountered after the age
of 30. Males are more frequently affected by traumatic injuries than females. Furthermore,
children known to participate in risk-related behaviors are more frequently affected than
those who abstain. A summary of risk factors for dental injuries is pictured in Fig 9-2.
Fig 9-1 Epidemiology of traumatic dental injuries (Andersson).
5% of bodily injuries in
orofacial region
1%–3% incidence of
traumatic dental injuries
20% prevalence in
permanent dentition
30% prevalence in
primary dentition
< 10 years
of age
Male sex
Risk-related
behavior
Fig 9-2 Factors associated with increased risk of traumatic
dental injury (Andersson).
The etiologic factors related to traumatic injuries are largely a function of patient age,
according to Andersson (Fig 9-3). In preschool-aged children, falls are the most common
cause of traumatic injuries. School-aged children experience injuries most frequently in re-
lation to sports incidents. In adolescents and young adults, trauma most frequently occurs
in relation to assaults and trafc incidents and is often related to alcohol use.
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179
Diagnosis
Pathophysiology
Pulpal inammation may occur following trauma, and spontaneous healing can occur in the
absence of bacteria without progression to endodontic infection. Kakehashi et al’s classic
experiment on germ-free rats demonstrated that bacteria are necessary for the progression
of pulpal disease to apical periodontitis (Fig 9-4). Without bacterial ingress, spontaneous
healing of the pulp can occur (Andreasen).
Bergenholtz proposed that microcracks in tooth
structure might allow progression of bacteria into the necrotic pulps of traumatized teeth
without direct exposure. Nagaoka et al suggested some immune protection is offered by
vital pulp whose loss, in the case of pulpal necrosis, might allow ingress of bacteria via
dentinal tubules. Once the key combination of bacteria and inammation is present in the
pulp, pulpal necrosis is inevitable.
Fig 9-3 Typical injury etiology by age (Andersson).
Preschool age School age
Adolescents and
young adults
Falls
Sports
incidents
Assaults
and trafc
incidents
Often
alcohol
related
Pulpal
inammation
Bacteria
Apical
periodontitis
Fig 9-4 Requirements for apical periodontitis (Kakehashi et al).
Diagnosis
The rst step in appropriate management of traumatic orofacial injuries is to perform a
rapid physical assessment. Steelman advised a primary survey following airway, breathing,
circulation, disability, and exposure (ABCDE). This primary survey ensures appropriate air-
way maintenance and cervical spine protection, adequate breathing and ventilation, intact
circulation without evidence of shock, evaluation for neurological disability, and that the
patient is exposed for a full examination. A secondary survey delves further into the medi-
cal history, requiring a patient interview for allergies, medications, past illnesses, last meal,
the events and environment leading to trauma, and tetanus vaccination history.
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180
Traumatic Dental Injuries
9
Following the rapid physical assessment and secondary survey, an oral examination
should be performed. An early assessment should triage for appropriate treatment timing.
Bakland and Andreasen proposed division of traumatic dental injuries into those with acute
priority requiring treatment within hours, those with subacute priority where delaying treat-
ment several hours should not affect the prognosis, and those with delayed priority where
a delay—even beyond 24 hours—should not affect the prognosis. Acute priority injuries
include root fractures, alveolar fractures, lateral luxation injuries, extrusive luxation injuries,
and avulsion injuries. Subacute priority injuries include complicated crown fractures with
pulp exposures, concussions, subluxations, and intrusions. Delayed priority injuries include
uncomplicated crown fractures without pulp exposures. A summary of Bakland and An-
dreasen’s recommendations for prioritizing dental injuries can be found in Fig 9-5.
InjuriesTreatment
Root fractures,
alveolar fractures,
lateral luxation,
extrusive luxation,
avulsions
Complicated
crown fractures.
concussions, sublux
-
ations, intrusions
Uncomplicated
crown fractures
Required within
hours
Can be delayed
several hours
Can be delayed
beyond 24 hours
Fig 9-5 Prioritization treatment (Bakland and Andreasen).
Acute priority Subacute priority Delayed priority
Diagnosis of traumatic dental injuries requires the accurate collection of both clinical and
radiographic data. Clinical data include both pulp sensitivity tests and periradicular tests.
Levin
reviewed specic pulpal and periradicular testing that should be performed to come
to a denitive diagnosis. Radiographic data should include periapical radiographs from
multiple angulations, as recommended by the AAE guidelines. If an alveolar fracture is sus-
pected, Levin suggested the use of a panoramic radiograph. Ball et al suggested that cone
beam computed tomography (CBCT) should be considered depending on the severity of
injury, as this may provide a more reliable assessment of the extent of the injury. Figure 9-6
summarizes the recommended systematic approach to evaluating patients presenting with
traumatic dental injuries.
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181
Diagnosis
Clinical exam
Baseline pulp sensitivity testing should occur at the earliest possible time following the
injury. The testing modality selected, namely thermal or electric pulp test (EPT), should take
into consideration the type of injury and the age of the patient.
In a tooth with a mature apex, the AAE guidelines consider a lack of response to pulp
sensitivity testing 3 months post-trauma as an indication of pulpal necrosis, and they advise
that pulpal necrosis should be diagnosed by at least two signs or symptoms. Bhaskar and
Rappaport found vital tissue in traumatized teeth nonresponsive to traditional pulp sensitivity
testing and advised a delay in diagnosis when relying on these methods alone due to pro-
posed transient sensory deciencies. Ozcelik et al’s histologic analysis showed intramyelin
edema, axonal swelling, and partial loss of the myelin sheath in the neurons of pulps ex-
posed in complicated coronal fractures, supporting this theory of neuronal injury. Although
not yet available to the clinician, Levin
suggested that, in the future, true pulp vitality tests
that evaluate the presence of vital tissue rather than sensitivity of the tissue, such as laser
Doppler owmetry, pulse oximetry, dual wavelength spectrophotometry, and thermography,
may bypass these limitations.
Levin recommended pulp sensitivity testing immediately post-trauma and again at 2 weeks,
4 weeks, 6 to 8 weeks, 6 months, and 1 year. Thermal testing is considered the gold standard
among available tests. EPT should be considered a secondary test, as its accuracy depends
on the circumstances. For example, Fulling and Andreasen found that EPT was not accurate in
immature teeth due to late development of the responsive A∂ nerve bers. EPT is considered
most useful to conrm suspected necrosis, based on reports by Peters et al and Gopikrishna
et al of its high positive predictive value. No response to EPT is highly predictive of a necrotic
pulp. Conversely, Ketterl reported an age-related reduction in dentinal tubule size and there-
fore the uid important in thermal testing, increasing the utility of EPT in the older patient.
Levin
further suggested that periradicular testing should include an assessment of mobility,
percussion, and palpation testing. Single-tooth mobility can assess the degree of dislodge-
ment of the tooth from the socket or a cervically located root fracture, whereas mobility of
several teeth in unison is often indicative of alveolar fracture. Percussion sensitivity in the acute
presentation of trauma can indicate recent attachment damage, whereas protracted or new
percussion sensitivity at follow-up oftentimes indicates infection or the presence of an alveo-
lar fracture. A metallic tone on percussion can indicate that a tooth is locked in bone related
to lateral or intrusive luxation injury or, in late stages of healing, that ankylosis has occurred.
Palpation allows one to feel alveolar fractures or the dislocation of a luxation injury. Palpation
sensitivity at follow-up can indicate infection or the presence of a nonhealing alveolar fracture.
1. Primary survey
• Airway
• Breathing
• Circulation
• Disability
• Exposure
2. Secondary survey
• Medical history
• Last meal
Events and envi-
ronment leading
to trauma
3. Focused
dental exam
Clinical
examination
Radiographic
examination
Fig 9-6 Recommended approach to the emergency patient presenting with a traumatic
dental injury (Steelman).
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182
Traumatic Dental Injuries
9
Clinical ndings
Clinical ndings are discussed by diagnostic entity as dened by the AAE guidelines.
Fractures (Fig 9-7)
Crown fractures can be divided into uncomplicated and complicated. For these injuries,
pulp sensitivity testing and mobility are generally normal, and teeth are not sensitive to
percussion. The exposed pulp can be sensitive to stimuli. If percussion tenderness is noted
during examination of a crown fracture, it is important to assess the patient for other trau-
matic injuries, namely concomitant luxation injuries, crown/root fractures and root fractures.
Uncomplicated fractures involve enamel and dentin without pulp exposure.
Complicated fractures involve enamel, dentin, and an exposed pulp.
Crown/root fractures involve enamel, dentin, and cementum and extend subgingivally.
A pulp exposure may or may not be noted. However, normal responses to pulp sensitiv-
ity testing are expected. Mobility and percussion tenderness are often present.
Root fractures involve root structure and may be located in the apical, middle, or cervi-
cal thirds of the root. The coronal fragment may be displaced and is often mobile, where-
as the apical segment is not often displaced. Percussion tenderness is common. Pulp
sensitivity testing may initially be nonresponsive, indicative of transient pulpal damage.
Alveolar fractures involve the fracture and mobility of a bony segment containing a sin-
gle tooth or several teeth. Often, if the fractured segment includes more than one tooth,
mobility of several teeth in concert is common. The fractured segment may be displaced,
creating occlusal interference.
Luxation-type injuries (Fig 9-8)
Concussion injuries present with percussion tenderness but lack displacement or mobil-
ity. Pulp sensitivity testing is usually normal.
Subluxation injuries present with percussion tenderness and mobility but lack displace-
ment. Pulp sensitivity testing may initially be nonresponsive, indicative of transient pulpal
damage, but is typically normal.
Uncomplicated:
Pulp is not
exposed
Complicated:
Pulp is
exposed
May be in apical,
middle,
or cervical thirds
Cor
onal portion
may be
displaced
Involve enamel,
dentin, and
cementum
Extend sub-
gingivally
May have pulp
exposur
e
May involve one
or mor
e teeth
Mobility and
displacement
common
Fig 9-7 Classication of fractures (AAE trauma guidelines).
Crown
fractures
Crown/root
fractures
Root
fractures
Alveolar
fractures
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9Traumatic Dental InjuriesThe abilities to diagnose and properly treat traumat-ic dental injuries are essential skills for the practicing endodontist. A joint symposium in 2012 between the American Association of Endodontists (AAE) and the American Academy of Pediatric Dentistry resulted in the release of a new set of guidelines on the diagnosis and treatment of traumatic dental injuries. The Ameri-can Board of Endodontics (ABE) exam requires intimate knowledge of these guidelines in addition to general fa-miliarity with the literature on which these guidelines are based. A 2013 supplement in the Journal of Endodon-tics was published with a specic focus on dental trauma in conjunction with the release of these guidelines. This chapter presents a review of traumatic dental injuries and their management and will largely focus on the per-manent dentition.http://dentalebooks.com 178Traumatic Dental Injuries9EpidemiologyTrauma to the orofacial region is a common nding in young patients, as reviewed by Andersson (Fig 9-1). Five percent of all bodily injuries are to the orofacial region, and this percentage increases substantially in preschool-aged children, where as many as 17% of all bodily injuries are to the orofacial region. Population-based studies indicate that the incidence of traumatic dental injuries is between 1% and 3%, and the prevalence is from 20% in the permanent dentition to 30% in the primary dentition. Of all patients seeking treatment for injuries to the orofacial region, 92% have experienced dental trauma, 28% have been affected by soft tissue injuries, and 6% have suffered jaw fractures. Injuries occur most frequently during the rst 10 years of life and are rarely encountered after the age of 30. Males are more frequently affected by traumatic injuries than females. Furthermore, children known to participate in risk-related behaviors are more frequently affected than those who abstain. A summary of risk factors for dental injuries is pictured in Fig 9-2. Fig 9-1 Epidemiology of traumatic dental injuries (Andersson).5% of bodily injuries in orofacial region 1%–3% incidence of traumatic dental injuries20% prevalence in permanent dentition30% prevalence in primary dentition< 10 years of ageMale sexRisk-related behaviorFig 9-2 Factors associated with increased risk of traumatic dental injury (Andersson).The etiologic factors related to traumatic injuries are largely a function of patient age, according to Andersson (Fig 9-3). In preschool-aged children, falls are the most common cause of traumatic injuries. School-aged children experience injuries most frequently in re-lation to sports incidents. In adolescents and young adults, trauma most frequently occurs in relation to assaults and trafc incidents and is often related to alcohol use. http://dentalebooks.com 179DiagnosisPathophysiologyPulpal inammation may occur following trauma, and spontaneous healing can occur in the absence of bacteria without progression to endodontic infection. Kakehashi et al’s classic experiment on germ-free rats demonstrated that bacteria are necessary for the progression of pulpal disease to apical periodontitis (Fig 9-4). Without bacterial ingress, spontaneous healing of the pulp can occur (Andreasen). Bergenholtz proposed that microcracks in tooth structure might allow progression of bacteria into the necrotic pulps of traumatized teeth without direct exposure. Nagaoka et al suggested some immune protection is offered by vital pulp whose loss, in the case of pulpal necrosis, might allow ingress of bacteria via dentinal tubules. Once the key combination of bacteria and inammation is present in the pulp, pulpal necrosis is inevitable. Fig 9-3 Typical injury etiology by age (Andersson).Preschool age School ageAdolescents and young adultsFallsSports incidentsAssaults and trafc incidentsOften alcohol relatedPulpal inammationBacteriaApical periodontitisFig 9-4 Requirements for apical periodontitis (Kakehashi et al).DiagnosisThe rst step in appropriate management of traumatic orofacial injuries is to perform a rapid physical assessment. Steelman advised a primary survey following airway, breathing, circulation, disability, and exposure (ABCDE). This primary survey ensures appropriate air-way maintenance and cervical spine protection, adequate breathing and ventilation, intact circulation without evidence of shock, evaluation for neurological disability, and that the patient is exposed for a full examination. A secondary survey delves further into the medi-cal history, requiring a patient interview for allergies, medications, past illnesses, last meal, the events and environment leading to trauma, and tetanus vaccination history. http://dentalebooks.com 180Traumatic Dental Injuries9Following the rapid physical assessment and secondary survey, an oral examination should be performed. An early assessment should triage for appropriate treatment timing. Bakland and Andreasen proposed division of traumatic dental injuries into those with acute priority requiring treatment within hours, those with subacute priority where delaying treat-ment several hours should not affect the prognosis, and those with delayed priority where a delay—even beyond 24 hours—should not affect the prognosis. Acute priority injuries include root fractures, alveolar fractures, lateral luxation injuries, extrusive luxation injuries, and avulsion injuries. Subacute priority injuries include complicated crown fractures with pulp exposures, concussions, subluxations, and intrusions. Delayed priority injuries include uncomplicated crown fractures without pulp exposures. A summary of Bakland and An-dreasen’s recommendations for prioritizing dental injuries can be found in Fig 9-5.InjuriesTreatmentRoot fractures, alveolar fractures, lateral luxation, extrusive luxation, avulsions Complicated crown fractures. concussions, sublux-ations, intrusionsUncomplicated crown fracturesRequired within hoursCan be delayed several hoursCan be delayed beyond 24 hoursFig 9-5 Prioritization treatment (Bakland and Andreasen).Acute priority Subacute priority Delayed priorityDiagnosis of traumatic dental injuries requires the accurate collection of both clinical and radiographic data. Clinical data include both pulp sensitivity tests and periradicular tests. Levin reviewed specic pulpal and periradicular testing that should be performed to come to a denitive diagnosis. Radiographic data should include periapical radiographs from multiple angulations, as recommended by the AAE guidelines. If an alveolar fracture is sus-pected, Levin suggested the use of a panoramic radiograph. Ball et al suggested that cone beam computed tomography (CBCT) should be considered depending on the severity of injury, as this may provide a more reliable assessment of the extent of the injury. Figure 9-6 summarizes the recommended systematic approach to evaluating patients presenting with traumatic dental injuries.http://dentalebooks.com 181DiagnosisClinical examBaseline pulp sensitivity testing should occur at the earliest possible time following the injury. The testing modality selected, namely thermal or electric pulp test (EPT), should take into consideration the type of injury and the age of the patient. In a tooth with a mature apex, the AAE guidelines consider a lack of response to pulp sensitivity testing 3 months post-trauma as an indication of pulpal necrosis, and they advise that pulpal necrosis should be diagnosed by at least two signs or symptoms. Bhaskar and Rappaport found vital tissue in traumatized teeth nonresponsive to traditional pulp sensitivity testing and advised a delay in diagnosis when relying on these methods alone due to pro-posed transient sensory deciencies. Ozcelik et al’s histologic analysis showed intramyelin edema, axonal swelling, and partial loss of the myelin sheath in the neurons of pulps ex-posed in complicated coronal fractures, supporting this theory of neuronal injury. Although not yet available to the clinician, Levin suggested that, in the future, true pulp vitality tests that evaluate the presence of vital tissue rather than sensitivity of the tissue, such as laser Doppler owmetry, pulse oximetry, dual wavelength spectrophotometry, and thermography, may bypass these limitations. Levin recommended pulp sensitivity testing immediately post-trauma and again at 2 weeks, 4 weeks, 6 to 8 weeks, 6 months, and 1 year. Thermal testing is considered the gold standard among available tests. EPT should be considered a secondary test, as its accuracy depends on the circumstances. For example, Fulling and Andreasen found that EPT was not accurate in immature teeth due to late development of the responsive A∂ nerve bers. EPT is considered most useful to conrm suspected necrosis, based on reports by Peters et al and Gopikrishna et al of its high positive predictive value. No response to EPT is highly predictive of a necrotic pulp. Conversely, Ketterl reported an age-related reduction in dentinal tubule size and there-fore the uid important in thermal testing, increasing the utility of EPT in the older patient.Levin further suggested that periradicular testing should include an assessment of mobility, percussion, and palpation testing. Single-tooth mobility can assess the degree of dislodge-ment of the tooth from the socket or a cervically located root fracture, whereas mobility of several teeth in unison is often indicative of alveolar fracture. Percussion sensitivity in the acute presentation of trauma can indicate recent attachment damage, whereas protracted or new percussion sensitivity at follow-up oftentimes indicates infection or the presence of an alveo-lar fracture. A metallic tone on percussion can indicate that a tooth is locked in bone related to lateral or intrusive luxation injury or, in late stages of healing, that ankylosis has occurred. Palpation allows one to feel alveolar fractures or the dislocation of a luxation injury. Palpation sensitivity at follow-up can indicate infection or the presence of a nonhealing alveolar fracture. 1. Primary survey • Airway • Breathing • Circulation • Disability • Exposure2. Secondary survey • Medical history • Last meal • Events and envi-ronment leading to trauma3. Focused dental exam • Clinical examination • Radiographic examinationFig 9-6 Recommended approach to the emergency patient presenting with a traumatic dental injury (Steelman).http://dentalebooks.com 182Traumatic Dental Injuries9Clinical ndings Clinical ndings are discussed by diagnostic entity as dened by the AAE guidelines.Fractures (Fig 9-7)Crown fractures can be divided into uncomplicated and complicated. For these injuries, pulp sensitivity testing and mobility are generally normal, and teeth are not sensitive to percussion. The exposed pulp can be sensitive to stimuli. If percussion tenderness is noted during examination of a crown fracture, it is important to assess the patient for other trau-matic injuries, namely concomitant luxation injuries, crown/root fractures and root fractures. • Uncomplicated fractures involve enamel and dentin without pulp exposure.• Complicated fractures involve enamel, dentin, and an exposed pulp. • Crown/root fractures involve enamel, dentin, and cementum and extend subgingivally. A pulp exposure may or may not be noted. However, normal responses to pulp sensitiv-ity testing are expected. Mobility and percussion tenderness are often present. • Root fractures involve root structure and may be located in the apical, middle, or cervi-cal thirds of the root. The coronal fragment may be displaced and is often mobile, where-as the apical segment is not often displaced. Percussion tenderness is common. Pulp sensitivity testing may initially be nonresponsive, indicative of transient pulpal damage. • Alveolar fractures involve the fracture and mobility of a bony segment containing a sin-gle tooth or several teeth. Often, if the fractured segment includes more than one tooth, mobility of several teeth in concert is common. The fractured segment may be displaced, creating occlusal interference. Luxation-type injuries (Fig 9-8)• Concussion injuries present with percussion tenderness but lack displacement or mobil-ity. Pulp sensitivity testing is usually normal. • Subluxation injuries present with percussion tenderness and mobility but lack displace-ment. Pulp sensitivity testing may initially be nonresponsive, indicative of transient pulpal damage, but is typically normal. • Uncomplicated: Pulp is not exposed• Complicated: Pulp is exposed• May be in apical, middle, or cervical thirds• Coronal portion may be displaced• Involve enamel, dentin, and cementum• Extend sub- gingivally• May have pulp exposure• May involve one or more teeth• Mobility and displacement commonFig 9-7 Classication of fractures (AAE trauma guidelines).Crown fracturesCrown/root fracturesRoot fracturesAlveolar fractureshttp://dentalebooks.com 183Diagnosis• Extrusive luxation injuries present with outward or incisal displacement and percus-sion tenderness. Pulp sensitivity testing is often nonresponsive. Mobility of the extruded tooth is often noted.• Lateral luxation injuries present with lateral displacement, oftentimes associated with a fracture of the facial cortical bone that can be palpable. The tooth may appear immo-bile or locked in bone and is typically percussion tender. Pulp sensitivity testing is often nonresponsive. • Intrusive luxation injuries present with displacement of the tooth into the alveolar bone, oftentimes associated with palpable fracture of the alveolar process. The tooth may ap-pear immobile or locked and is typically percussion tender. Pulp sensitivity testing is often nonresponsive. Fig 9-8 Luxation-type injuries (AAE trauma guidelines).Luxation injuriesSubluxationIntrusive luxationExtrusive luxationLateral luxationConcussionAvulsionsAvulsion involves complete loss of a tooth from its socket, with possible fracture of the associated alveolar bone. Treatment plans must take into account the stage of root matu-ration, extraoral dry time prior to replantation, and particular extraoral storage media used. Radiographic examinationRadiographic examination is essential following dental trauma. The AAE guidelines gener-ally advise taking at least two periapical radiographs from different horizontal angulations. Depending on the type of injury suspected based on the history and clinical and preliminary radiographic exams, additional radiographs are often suggested as outlined below. Ball et al suggested the addition of CBCT imaging in many cases of traumatic dental injuries.http://dentalebooks.com 184Traumatic Dental Injuries9Radiographic ndings Radiographic ndings are unique to each diagnostic entity, according to the AAE guide-lines. Examples of traumatic injuries are shown in Fig 9-9.Fig 9-9 Radiographic presentations of traumatic dental injuries. (a) Uncomplicat-ed crown fracture. (b) Complicated crown fracture. (c) Horizontal root fracture. (d) Concussion. (e) Subluxation. (f) Extrusive luxation. (g) Lateral luxation. (h) Intrusive luxation. (i) Avulsion.adgcfibehFracturesIn cases of suspected tooth or alveolar fracture, one occlusal and at least two periapical radiographs of varying horizontal angulation should be taken. When a root fracture is sus-pected, Bender and Freedland suggested that periapical radiographs of several varying http://dentalebooks.com 185Treatment Protocolsvertical angulations can be helpful. If soft tissue lacerations are noted, radiographs should be taken of the lacerations to identify any tooth fragments or foreign material contained within the soft tissue wound. CBCT images are suggested when there is suspicion of a root fracture; however, the resolution of CBCT images may not identify certain fractures if fragment separation is insufcient. Brady et al found that vertical root fractures smaller than 50 µm were not detectable in the particular CBCT machines studied. CBCT or panoramic radiographic images are suggested when there is suspicion of alveolar fracture. Luxation-type injuriesFor all luxation-type injuries, two periapical radiographs from varying horizontal angula-tions are recommended to evaluate for displacement. For extrusive, lateral, and intrusive luxation injuries, an occlusal lm should be added to the radiographic exam. The peri-odontal ligament (PDL) should be closely evaluated, as extrusive and lateral luxation in-juries often present with an enlarged PDL space, whereas intrusive luxation injuries may present with either full or partial loss of the PDL. A CBCT image is suggested depending on the severity of the injuries, specically to evaluate the PDL and the alveolar bone for the presence or absence of fracture. If a tooth is completely intruded, a lateral cephalogram is recommended to evaluate for penetration into the nasal cavity. AvulsionsFor all avulsion injuries, two periapical radiographs from mesial and distal angulations are recommended as well as a CBCT image to conrm proper repositioning and evaluate for any alveolar fractures. Treatment ProtocolsSplintingThe International Association of Dental Traumatology (IADT) states that, following trau-ma, splinting is used to maintain the correct tooth position, provide patient comfort, and improve function (Diangelis et al). The AAE guidelines exclusively advise the use of exible splints when splinting is indicated, with wire diameter not to exceed 0.016 inches or 0.4 mm. Von Arx et al provid-ed an argument for nonrigid splinting. In studies on nonhuman primates, PDL damage and replace-ment resorption were noted when rigid splints were used following traumatic injuries. In addition to the use of exible splints, shorter splinting times are indicated. Nasjleti et al found that a splinting time of 7 days resulted in signicantly less replacement resorption than 30 days, following experimental avulsive injuries in monkeys. The guidelines for splinting are described in Fig 9-10. Table 9-1 sum-marizes recommended splint times for each diag-nostic entity. Fig 9-10 Requirements for splint-ing (AAE trauma guidelines).FlexibleShort durationhttp://dentalebooks.com 186Traumatic Dental Injuries9Fractures• Crown fractures should be treated with appropriate restorative materials or rebonding of available tooth fragments. If a denitive restoration cannot be placed immediately, sensi-tive areas of exposed dentin in uncomplicated fractures can be covered with glass ionomer or bonded resins. In complicated fractures, it is important to preserve pulp vitality with pulp capping or partial pulpotomy using calcium hydroxide or mineral trioxide aggregate. • Crown/root fracture management depends on the extent of injury. Without a pulp expo-sure, the fractured segment can be removed with or without a gingivectomy to restore. If pulp exposure is present, immature teeth should be managed with a partial pulpotomy to attempt to maintain vitality of the root pulp. Mature teeth should be treated with root canal therapy and restored appropriately. More extensive crown/root fractures may require orthodontic or surgical extrusion for restoration or may even require extraction. • Root fractures may present with full loss of the coronal segment, in which case they should be managed as avulsive injuries, as described later in this chapter. Repositioning of a displaced coronal segment should occur as soon as possible, and following radio-graphic conrmation of correct positioning, a exible splint should be placed for 4 weeks Injury Splinting time Follow-up timesCrown fractures NA 6–8 w, 1 yCrown/root fractures NA 6–8 w, 1 yRoot fractures 4 w if in the middle or apical third;4 m if in the coronal third4 w, 6–8 w, 4 m, 6 m, 1 y, yearly for 5 yAlveolar fracture 4 w 4 w, 6–8 w, 4 m, 6 m, 1 y, yearly for 5 yConcussion NA 2 w, 4 w, 6–8 w, 6 m, 1 y, yearly for 5 ySubluxation 2 w 2 w, 4 w, 6–8 w, 6 m, 1 y, yearly for 5 yExtrusive luxation 2 w 2 w, 4 w, 6–8 w, 6 m, 1 y, yearly for 5 yLateral luxation 2 w; if extensive luxation, can splint 4 w 2 w, 4 w, 6–8 w, 6 m, 1 y, yearly for 5 yIntrusive luxation 2 w; if extensive luxation, can splint 4 w 2 w, 4 w, 6–8 w, 6 m, 1 y, yearly for 5 yAvulsed tooth, mature apex 1–2 w 2 w, 4 w, 3 m, 6 m, 1 y, yearly for 5 yAvulsed tooth, immature apex1–2 w;if extraoral dry time > 60 min, splint 4 w2 w, 4 w, 3 m, 6 m, 1 y, yearly for 5 yNA, not applicable; min, minute; w, weeks; m, months; y, years.Table 9-1 Summary of treatment protocols for traumatic dental injurieshttp://dentalebooks.com 187Treatment Protocolsor as long as 4 months for cervically located root fractures. If pulpal necrosis develops, root canal therapy should be completed on the coronal segment only to the level of the fracture with the use of calcium hydroxide as an intracanal medicament. Cvek et al (2001) reported markedly improved success rates when root canal therapy was completed only to the level of the fracture rather than beyond. • Alveolar fractures should be managed by repositioning and stabilization with a exible splint for 4 weeks. Clinical and radiographic follow-ups for crown and crown/root fractures should be per-formed at 6 to 8 weeks and 1 year post-trauma. Root and alveolar fractures should have clinical and radiographic follow-ups at 4 weeks, 6 to 8 weeks, 4 months, 6 months, 1 year, and yearly thereafter for 5 years. Complications requiring intervention can develop at any time. Andreasen and Hjorting-Hansen described the types of healing following root fracture: calcied tissue, connective tissue wherein the pulp space is often obliterated, a combination of these two tissues, or nonhealing cases with granulation tissue at the site of fracture and associated pulpal necrosis (Fig 9-11). At follow-up, it is important to note the type of healing occurring for root fractures. Table 9-1 summarizes follow-up times for all diagnostic entities. Fig 9-11 Types of healing following root fracture (Andreasen and Hjorting-Hansen).Calcied tissueNonhealing/granulation tissue• Pulpal necrosisConnective tissue• Canal obliteration commonCombination calcied and connective tissueLuxation-type injuries • Concussion injuries do not require immediate treatment. • Subluxation injuries may be splinted for up to 2 weeks for patient comfort. • Extrusive luxation injuries should be immediately repositioned and splinted for up to 2 weeks. • Lateral luxation injuries should be repositioned, which may involve disengagement from a bony lock, followed by splinting for 2 weeks or up to 4 weeks for more extensive displacement. • Intrusive luxation injuries are managed differently based on the stage of root develop-ment and the extent of intrusion (Fig 9-12): http://dentalebooks.com 188Traumatic Dental Injuries9 – Teeth with incompletely formed apices intruded up to 7 mm should be allowed to spontaneously re-erupt. If re-eruption does not occur within 3 weeks, orthodontic re-positioning should be initiated. With intrusion greater than 7 mm, surgical or orthodon-tic repositioning should be initiated within 3 weeks. – Mature teeth intruded up to 3 mm should be allowed to spontaneously re-erupt with-out intervention. If re-eruption does not occur within 2 to 3 weeks, surgical or or-thodontic repositioning should be initiated before ankylosis develops. For intrusion between 3 and 7 mm, surgical or orthodontic repositioning should be initiated within 3 weeks. For intrusion greater than 7 mm, the tooth should be surgically repositioned and splinted for 2 weeks or up to 4 weeks for extensive displacement. For concussion, subluxation, extrusive, and lateral luxation injuries, the pulpal response to sensitivity and vitality testing should be monitored for 3 months before a denitive pul-pal diagnosis and decision to initiate endodontic therapy is made, unless pulpal necrosis is conrmed sooner with at least two signs or symptoms. Root canal therapy is the treatment of choice for mature teeth with pulpal necrosis, whereas pulp revascularization therapy or apexication should be considered for immature teeth. Intrusive luxation injuries of mature teeth are likely to result in pulpal necrosis, and root canal therapy should be initiated with-in 2 weeks of injury with 4 weeks of intracanal calcium hydroxide following pulpectomy. Immature teeth with intrusive luxation injuries may escape pulpal necrosis and should be monitored the same as the other luxation-type injuries. There is currently no strong evi-dence to support orthodontic versus surgical repositioning of intrusively luxated teeth that do not spontaneously re-erupt. In a systematic review, Al Khalifa and Al Azemi reported Fig 9-12 Treatment guidelines for intrusive luxations (AAE trauma guidelines). w, weeks.Allow spontaneous re-eruptionIf none within 3 w, orthodontic repositioningSurgical/orthodontic repositioningImmature teeth≤ 7-mm intrusion> 7-mm intrusionMature teeth3- to 7-mm intrusion< 3-mm intrusion> 7-mm intrusionIf none within 3 w, surgical or orthodontic repositioningAllow spontaneous re-eruptionSurgical or orthodontic repositioningSurgically reposition and splint 2–4 whttp://dentalebooks.com 189Treatment Protocolsonly 5% to 12% failure of spontaneous re-eruption and no difference in adverse outcomes between orthodontic versus surgical respositioning of these teeth. Clinical and radiographic follow-ups for all luxation-type injuries are recommended at 2 weeks, 4 weeks, 6 to 8 weeks, 6 months, 1 year, and yearly thereafter for 5 years. Com-plications requiring intervention can develop at any time. Table 9-1 summarizes follow-up times for all diagnostic entities. Avulsions The goal in treatment of avulsed teeth is to maintain the PDL, as most complications re-sult from injury to this structure. Van Hassel et al showed that removal of the PDL resulted in severe, progressive root resorption. Though the dental pulp is anticipated to undergo necrosis following avulsive injuries, particularly in mature teeth, pulpal infection should be minimized to prevent progression of apical periodontitis. According to Andreasen et al, the prognosis of avulsed teeth is highly dependent on the status of root maturation, the time to replantation, and the extraoral storage media. Therefore, treatment protocols differ depending on these variables. Historically, because avulsed teeth with immature roots or open apices had a poor prognosis following replantation, older guidelines advised that these not be replanted in all cases. More recently, thought has shifted, and modications to treatment protocols have been made in the new AAE guidelines, including the replantation of these teeth despite the poor prognosis. This recommendation was made in order to maintain bone volume in the area of the avulsion and improve the feasibility of dental implant placement in the fully grown patient. Replantation of avulsed teeth is recommended as soon as possible because extraoral dry time should ideally fall under 60 minutes. Extraoral storage should be in a physiologic storage media because dry storage leads to rapid PDL cell death and inevitable root re-sorption, and nonphysiologic solutions, such as water, can lead to cell lysis via osmosis. Hank’s balanced salt solution (HBSS), saline (supported by Trope and Friedman), and milk (supported by Blomlof) are the recommended storage media (Fig 9-13). More recently, novel storage media including soy milk and coconut water have been proposed due to their rich nutrient content. In a study by de Paula Reis et al, coconut water showed promise, but in-creased levels of replacement resorption were noted with soy milk storage. Following avulsion injuries, systemic antibiotics are recommended. Doxycycline is the drug of choice in patients over 12 years old. Due to the risks of staining the developing dentin that are associated with doxycycline, amoxicillin is recommended for patients un-der 12 years old. The recommendation of doxycycline is extrapolated from Sae-Lim et al’s report of tetracycline’s antiresorptive properties due to reduced osteoclast motility and collagenase function. Hammarström et al supported the general use of systemic antibi-otics to prevent external root resorption, and his work is the basis for the suggested use of amoxicillin when doxycycline is contraindicated. If tetanus coverage is uncertain, the patient should be referred to their physician for a tetanus booster. Fig 9-13 Ideal storage media for avulsed teeth (AAE trauma guidelines).HBSS Saline Milkhttp://dentalebooks.com 190Traumatic Dental Injuries9Specic treatment recommendations vary according to the status of root maturation, the extraoral dry time, and the particular extraoral storage media used (Fig 9-14). Following are the guidelines based on these variables: Fig 9-14 Treatment guidelines for avulsed teeth (AAE trauma guidelines) d, days; RCT, root canal treatment; w, weeks.Mature teethAlready replantedImproper extraoral storageProper extraoral storageLeave in place and splint 1–2 wRCT wtihin 7–10 dRCT within 7–10 dSodium uoride soak prior to reposition and splint 1–2 wReposition and splint 1–2 wExtraoral RCT or within 7–10 dImmature teethAlready replantedImproper extraoral storageProper extraoral storageLeave in place and splint 2 wWatch for pulpal necrosisWatch for pulpal necrosisExtraoral RCTDoxycycline soak prior to reposition and splint 2 wReposition and splint 4 whttp://dentalebooks.com 191Treatment ProtocolsMature teeth with closed apex• If the tooth has already been replanted, it should be left in place, and its position should be conrmed radiographically. A exible splint should be placed for 1 to 2 weeks. Root canal therapy should be initiated between 7 and 10 days postreplantation while the splint is still in place. Interappointment intracanal calcium hydroxide should be placed for at least 4 weeks. Trope et al reported markedly reduced external inammatory root resorption when long-term calcium hydroxide was used following avulsive injuries. Alter-natively, root canal therapy could be initiated immediately following replantation using a corticosteroid as the intracanal medication for at least 2 weeks. Bryson et al reported reduced resorption with intracanal Ledermix cement [Dentsply]. • If the tooth has been kept in a physiologic storage medium, such as HBSS, saline, or milk, and/or stored dry for less than 60 minutes, the root and socket should be cleaned gently with a saline rinse and the tooth replanted under local anesthesia. Placement should be conrmed radiographically before a exible splint is placed for 1 to 2 weeks. Root canal therapy is indicated similarly to the previously replanted tooth. • If the tooth has been kept dry and out of the mouth for more than 60 minutes, the root should be cleaned gently using dry gauze. Prior to replantation, a 20-minute soak in a 2% sodium uoride solution can be considered as a means of potentially slowing replace-ment resorption, based on the work of Coccia, but is not an absolute recommendation. Replantation should occur as above, followed by placement of a exible splint for 1 to 2 weeks. Root canal therapy could be completed extraorally prior to replantation or based on the same methodology recommended for the tooth that was already replanted on presentation. Replacement resorption is considered an inevitable complication with pro-longed extraoral dry time because of PDL cell death, and decoronation according to the protocol proposed by Malmgren is advised once the tooth is greater than 1 mm infrapo-sitioned. The decoronation procedure involves removal of the coronal tooth structure, with possible use of this fragment as a bonded temporary, followed by surgical access to remove any root lling material, contouring of the root structure, and reapproximation of the ap. Once replacement resorption is complete, a dental implant can be placed. Immature teeth with open apex• If the tooth has already been replanted, it should be left in place, and its position should be conrmed radiographically. A exible splint should be placed for 2 weeks. Revascu-larization will ideally occur without endodontic intervention. Kling et al found an 18% incidence of revascularization following avulsion injuries in immature teeth with apical diameter greater than 1 mm. If evidence of pulpal necrosis is found before root matu-ration is complete, regenerative endodontic therapy or apexication is recommended. • If the tooth has been kept in a physiologic storage medium, such as HBSS, saline, or milk, or stored dry for less than 60 minutes, the root and socket should be cleaned gently with a saline rinse and the tooth replanted under local anesthesia. Prior to replantation, a 20- minute soak in 1 mg/mL minocycline or doxycycline solution is indicated based on the work of Cvek et al (1990), which suggested its ability to improve revascularization. Place-ment should be conrmed radiographically before a exible splint is placed for 2 weeks. As with the tooth that has already been replanted, revascularization will ideally occur with-out endodontic intervention, but if evidence of pulpal necrosis is found before root mat-uration is complete, regenerative endodontic therapy or apexication is recommended. http://dentalebooks.com 192Traumatic Dental Injuries9• If the tooth has been kept dry and out of the mouth for more than 60 minutes, the root should be cleaned gently using dry gauze. Root canal therapy should be completed extra-orally prior to replantation. Replantation should occur as above, followed by placement of a exible splint for 4 weeks. Replacement resorption is considered an inevitable complication with prolonged extraoral dry time due to PDL cell death, and decoronation according to the protocol proposed by Malmgren is advised once the tooth is greater than 1 mm infrapo-sitioned. Since tooth loss is an anticipated eventuality, growth monitoring via height and weight tracking is suggested to determine when dental implant placement is advisable. Clinical and radiographic follow-ups for all avulsion injuries are recommended at 4 weeks, 3 months, 6 months, 1 year, and yearly thereafter for 5 years. Complications requiring interven-tion can develop at any time. Table 9-1 summarizes follow-up times for all diagnostic entities. Postoperative instructionsThe AAE guidelines recommend a soft diet for 1 to 2 weeks following traumatic dental in-juries, depending on the severity of injury. Good oral hygiene with the use of a soft-bristled toothbrush should be maintained, and a 0.12% chlorhexidine mouthrinse should be used twice daily for 2 weeks following luxation-type and avulsion injuries. Contact sports should be avoided for at least 2 weeks following avulsion injuries, and on resuming contact sports, mouth guards should be worn. Primary dentitionThe goal in management of traumatic injuries to the primary dentition is to minimize any damage to or lasting effects on the underlying permanent dentition, as the primary and per-manent dentition are situated in extremely close proximity during development. The IADT generally advises restorative repair of more supercial fractures and potential pulp cap or at most extreme pulpotomy as the only endodontic treatment recommended (Malmgren). Should evidence of pulpal involvement necessitating greater intervention be present, ex-traction is advised. For luxation injuries where repositioning will not damage the successor tooth, careful repositioning can be considered; however, when the permanent tooth is at risk with repositioning, extraction is advised. Similarly, if postoperative complications arise requir-ing more invasive treatment, extraction of the primary tooth is recommended to preserve the health of its permanent successor. Splinting is advised for alveolar fractures but not for fracture or luxation injuries. Systemic antibiotics are not recommended. Otherwise, postoper-ative instructions involving maintenance of good hygiene and avoidance of further injury are similar to that of the permanent dentition. The IADT advises against replantation of avulsed primary teeth because of the high risk of damaging the permanent successors. PrognosisOutcomes for the traumatically injured tooth are a function of the extent and type of the injury, the stage of root development, and appropriate treatment at the time of injury, according to Levin. Table 9-2 presents commonly reported values for the percentages of teeth that maintain their vitality following traumatic dental injuries. 193ComplicationsComplicationsThe complications encountered following traumatic dental injuries to the permanent denti-tion are a function of the stage of tooth development and the extent and type of injury. The incidence of necrosis following injury ranges from as little as 3% in concussions to 100% in the instance of an avulsed mature tooth, as seen in Table 9-2. Hecova et al reported a higher inci-dence of pulpal necrosis following traumatic injuries of mature rather than immature teeth. The diagnosis of necrosis following trauma requires at least two signs or symptoms as false neg-ative results to pulp sensitivity tests are frequently encountered, especially in the early stages following traumatic dental injuries. Pulpal necrosis requires treatment appropriate for the stage of root development, namely root canal therapy or apexication or regenerative procedures. Another complication frequently encountered following traumatic dental injuries is pulp ca-nal obliteration (PCO), which presents as narrowing of the canal space following trauma. An-dreasen and Pedersen described PCO as occurring mainly in teeth with open apices and may be a result of revascularization. Histologically, Lundberg and Cvek described PCO tissues as osteoid with little inammation or bacterial contamination. Jacobsen and Kerekes found PCO in as many as 40% of luxated teeth and as few as 8% of root-fractured teeth. PCO itself does not necessitate dental treatment, as Andreasen and Pedersen found that only 7% of teeth ex-hibiting PCO develop pulp necrosis. No higher frequency of pulp necrosis was noted in teeth with PCO when compared with normal teeth when subjected to caries, new trauma, orthodon-tic treatment, or complete crown restoration. Although the incidence of pulp necrosis in teeth displaying PCO seems to increase over time, Robertson et al advised against prophylactic endodontic treatment due to the relatively low lifetime risk of pulpal necrosis. Resorption may also be encountered following traumatic injuries to the dentition. In-ternal, invasive cervical, external, and replacement resorption have all been noted follow-ing traumatic dental injuries. According to Tronstad, internal resorption is encountered following coronal necrosis of pulp tissue. Gabor et al reported histologic signs of internal resorption in as many as 50% of teeth with irreversible pulpitis and 77% of teeth with pulp InjuryTeeth that maintain vitality (%) ReferenceCrown fracture 94 RavnRoot fracture 78 Andreasen et alConcussion 97 Andreasen and PedersenSubluxation 94 Andreasen and PedersenExtrusive luxation 74 Andreasen and PedersenLateral luxation 42 Andreasen and PedersenIntrusive luxation 15 Andreasen and PedersenAvulsion (mature tooth) 0 Kling et alAvulsion (immature tooth) 18 Kling et alTable 9-2 Prognosis of traumatically injured teeth 194Traumatic Dental Injuries9necrosis, even in the absence of clinical evidence. Invasive cervical root resorption is gen-erally a late complication noted incidentally on clinical or radiographic examination.Van Hassel et al pointed to PDL damage resulting from traumatic dental injuries as the major etiologic factor in external resorption. According to Trope, clastic cells from the PDL may be stimulated by necrotic pulp tissue to resorb dental hard tissues that have lost their protective, unmineralized layer. External inammatory root resorption is a frequent com-plication encountered following avulsions but may occur following any traumatic injury. After an avulsion, maintenance of the PDL cells with prompt replantation and appropriate extraoral storage media, including HBSS, saline, and milk, may limit external resorption. Some evidence exists to support the use of systemic antibiotics following replantation as well. Hammarström et al suggested a preventive action of systemic antibiotics at the time of injury but not weeks later. Once resorption is initiated, however, Trope et al recommend-ed root canal therapy with long-term calcium hydroxide to prevent progression of the resorptive defect. Alternatively, an intracanal corticosteroid such as Ledermix may be used according to Bryson et al.Replacement resorption, otherwise known as ankylosis, is yet another potential compli-cation following traumatic dental injuries. Tronstad described replacement resorption as osteoblastic repopulation of resorptive lacunae causing the defect to ll in with bone rather than cementum or PDL tissues. This process continues, leading to the replacement of root structure with bone. Common clinical ndings with replacement resorption include a me-tallic tone to percussion, a lack of physiologic mobility, and infrapositioning in a growing patient. Like external resorption, this may occur following any traumatic injury. Following avulsion injuries with extraoral dry times beyond 60 minutes, the AAE guidelines suggest that replacement resorption is inevitable. It is therefore necessary to discuss this likely out-come with patients and parents to prepare them for its occurrence. Tronstad reported that replacement resorption itself is untreatable and will continue until the entire root structure is replaced by bone. In the growing patient where infrapositioning is a likely occurrence, the AAE guidelines advise decoronation once the position is 1 mm apical to the neighbor-ing teeth. Malmgren described a useful protocol for decoronation, discussed previously with the treatment of avulsive injuries. External apical root resorption (EARR), also referred to as pressure resorption, is asso-ciated with orthodontic movement of previously traumatized teeth (Brin et al). Obviously, orthodontic movement cannot be avoided for a patient’s lifetime following traumatic inju-ries, but there is no consensus in the literature on the appropriate amount of time to wait to resume or commence orthodontic movement following trauma. Kindelan et al suggested a range of between 3 months for minor injuries and up to 1 year following severe injuries; however, they point out that these recommendations are based on empirical rather than scientic data. Pereira et al, based on experimental work on a rat model, noted that a delay of 15 to 30 days should be sufcient to resume orthodontic movement following a subluxation injury.Figure 9-15 summarizes the potential complications following traumatic dental injuries, and Fig 9-16 shows radiographic examples of such complications. For additional informa-tion on resorption, please refer to chapter 10. 195PreventionPreventionMouth guards are the best form of protection from traumatic dental injuries during contact sports. The AAE suggests fabricating custom-made mouth guards for proper extension en-suring adequate protection and comfort. Sigurdsson speculated that these mouth guards are helpful in the protection of hard tissue but not soft tissue injuries. Although some historic literature suggested that mouth guards might also prevent concussions and other brain injuries, Sigurdsson found no support for this. In society, a wide range of actions can be implemented in the prevention of traumatic dental injuries. Andersson advised that the focus of these actions should be on personal and social education aimed at developing life skills and social policies against bullying and violence, physical environment changes, school health policies, alcohol policies, school provision of mouth guards, and links with health services. Fig 9-16 Examples of complications following traumatic dental injuries. (a) Internal root resorption, (b) external inammatory root resorption and replacement resorption, and (c) PCO. Pulpal necrosisInternalInvasive cervicalExternalReplace-mentComplicationsPCO ResorptionFig 9-15 Potential complications following traumatic dental injuries.a cb 196Traumatic Dental Injuries9BibliographyIntroductionAmerican Association of Endodontists. Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries. http://www.aae.org/clinical-re-sources/trauma-resources.aspx. Accessed 8 January 2016.EpidemiologyAndersson L. Epidemiology of traumatic dental injuries. J Endod 2013;39:S2–S5.PathophysiologyAndreasen FM. Pulpal healing after luxation injuries and root fracture in the permanent denti-tion. Endod Dent Traumatol 1989;5:111–131.Bergenholtz G. Micro-organisms from necrotic pulp of traumatized teeth. Odontol Revy 1974;25:347–358.Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. 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