1

TRAUMATIC DENTAL INJURIES– A Manual

Third EditionJ. O. ANDREASEN

L. K. BAKLAND

M. T. FLORES

F. M. ANDREASEN

L. ANDERSSON

2

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.

Registered offi ceJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom

Editorial offi ces9600 Garsington Road, Oxford, OX4 2DQ, United KingdomThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom2121 State Avenue, Ames, Iowa 50014-8300, USA

First edition published 1999Second edition 2003Third edition 2011

For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.

The right of the author to be identifi ed as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

Library of Congress Cataloging-in-Publication DataTraumatic 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

3

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 Third Edition

4

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 - 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 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

Preface to First 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. FloresCopenhagen, January 2003

Preface to Second Edition

5

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

Contributors

7

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

8

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.

Traumatic Dental Injuries: A Manual, Third Edition © J.O. Andreasen, L.K. Bakland, M.T. Flores, F.M. Andreasen and L. AnderssonPublished 2011 by Blackwell Publishing Ltd

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 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

9

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

100

90

80

70

50

60

20

30

40

10

0

CAUSE OF TRAUMA RELATED TO SEX

Bicycles Violence Sports Falls Misc.

%

Boys

Girls

CAUSE OF TRAUMA RELATED TO SEX AND AGE

0-6 years 7-15 years 16-30 yearsFalls Push/ Hit Falls Push/ Hit Falls Push/ Hit

100

90

80

70

50

60

20

30

40

10

0

%

Boys

Girls

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 denti-tion are falls, followed by traffi c 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