Bibliographic Source(s)

• American Academy of Pediatric Dentistry (AAPD). Guideline on management of acute dental trauma. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2007. 14 p. [81 references]

Guideline Status

This is the current release of the guideline.

It updates a previously published version: American Academy of Pediatric Dentistry. Clinical guideline on management of acute dental trauma. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 8 p.

Guideline Category

Diagnosis
Management
Treatment

Intended Users

Dentists
Emergency Medical Technicians/Paramedics
Health Care Providers
Health Plans
Managed Care Organizations
Physicians
Public Health Departments

Guideline Objective(s)

To define describe appearances and set forth objectives for general management of acute traumatic dental injuries

Target Population

Children with acute traumatic dental injuries

Interventions and Practices Considered

Diagnosis

1. Radiographic assessment
2. Clinical assessment

Management/Treatment

1. Flexible splinting
2. Maintaining pulp vitality with continued monitoring endodontic treatment and reattachment of the crown fragment
3. Restoring normal esthetics and function with fixed or removable appliances
4. Examining injured lips tongue and gingiva for tooth fragments
5. For small fractures smoothing rough margins and edges
6. Pulpal treatment alternatives for primary teeth:
   • Pulpotomy
   • Pulpectomy
   • Extraction
7. Pulpal treatment alternatives for permanent teeth:
   • Direct pulp capping
   • Partial pulpotomy
   • Pulpectomy (start of root canal therapy)
8. Tooth removal
9. Coronal fragment removal followed by supragingival restoration or necessary gingivectomy; osteotomy; or surgical or orthodontic extrusion to prepare for restoration
10. Repositioning of displaced tooth (passive active and/or surgical)
11. Tooth replantation
12. Tetanus prophylaxis
13. Antibiotic coverage
14. Antiresorptive-regenerative therapies

Major Outcomes Considered

• Pulp vitality
• Esthetics and function

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

A MEDLINE search was conducted using the terms "teeth" "trauma" "permanent teeth" and "primary teeth." Also a review of the journal Dental Traumatology was conducted for the years 2000-2006.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Subjective Review

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

This guideline is based on a review of the current dental and medical literature related to dental trauma.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).

Proposals to develop or modify guidelines may originate from 4 sources:

1. The officers or trustees acting at any meeting of the Board of Trustees
2. A council committee or task force in its report to the Board of Trustees
3. Any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
4. Officers trustees council and committee chairs or other participants at the AAPD's Annual Strategic Planning Session

Regardless of the source proposals are considered carefully and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.

Once a charge (directive from the Board of Trustees) for development or review/revision of a clinical guideline is sent to the CCA it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a guideline. All clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. CCA in collaboration with the Council on Scientific Affairs performs a comprehensive review of current scientific literature for each document. In cases where scientific data does not appear conclusive experts may be consulted.

The CCA meets on an interim basis (midwinter) to discuss proposed clinical guidelines. Each new or reviewed/revised guideline is reviewed discussed and confirmed by the entire council.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Comparison with Guidelines from Other Groups
Peer Review

Description of Method of Guideline Validation

Once developed by the Council on Clinical Affairs (CCA) the proposed guideline is submitted for the consideration of the Board of Trustees. While the board may request revision in which case it is returned to the council for modification once accepted by majority vote of the board it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly either as proposed or as amended by that body the document then becomes the official American Academy of Pediatric Dentistry (AAPD) clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.

Major Recommendations

Infraction

Definition: Incomplete fracture (crack) of the enamel without loss of tooth structure

Diagnosis: Normal gross anatomic and radiographic appearance; craze lines apparent especially with transillumination

Treatment Objectives: To maintain structural integrity and pulp viability (Andreasen & Andreasen 1994; Robertson 1998; Ravn "Follow-up study of permanent incisors with enamel cracks" 1981)

General Prognosis: Complications are unusual (Olsburgh Jacoby & Krejci 2002).

Crown Fracture - Uncomplicated

Definition: An enamel fracture or an enamel-dentin fracture that does not involve the pulp

Diagnosis: Clinical and/or radiographic findings reveal a loss of tooth structure confined to the enamel or to both the enamel and dentin (Flores et al. "Guidelines part 1" 2001; Flores et al. "Guidelines part 3" 2001; Flores 2002; Andreasen & Andreasen 2000; Holen & McTigue 2005; Borum & Andreasen 1998.; Fried & Erickson 1995; McTigue 2005; Robertson 1998; Ravn "Follow-up study of permanent incisors with enamel fractures" 1981; Ravn "Follow-up study of permanent incisors with enamel-dentin fractures" 1981).

Treatment Objectives: To maintain pulp vitality and restore normal esthetics and function. Injured lips tongue and gingiva should be examined for tooth fragments. For small fractures rough margins and edges can be smoothed. For larger fractures the lost tooth structure can be restored (Flores et al. "Guidelines part 1" 2001; Flores et al. "Guidelines part 3" 2001; Flores 2002; Andreasen & Andreasen 2000; Holan & McTigue 2005; Borum & Andreasen 1998.; Fried & Erickson 1995; American Academy of Pediatric Dentistry [AAPD] 2002; McTigue 2005; Robertson 1998; Olsburgh Jacoby & Krejci 2002; Ravn "Follow-up study of permanent incisors with enamel fractures" 1981; Ravn "Follow-up study of permanent incisors with enamel-dentin fractures" 1981).

General Prognosis: The prognosis of uncomplicated crown fractures depends primarily upon the concomitant injury to the periodontal ligament and secondarily upon the extent of dentin exposed (Andreasen & Andreasen 2000). Optimal treatment results follow timely assessment and care.

Crown Fracture - Complicated

Definition: An enamel-dentin fracture with pulp exposure

Diagnosis: Clinical and radiographic findings reveal a loss of tooth structure with pulp exposure (Flores et al. "Guidelines part 1" 2001; Flores et al. "Guidelines part 3" 2001; Flores 2002; Andreasen & Andreasen 2000).

Treatment Objectives: To maintain pulp vitality and restore normal esthetics and function (AAPD 2002). Injured lips tongue and gingiva should be examined for tooth fragments.

• Primary Teeth: Decisions often are based on life expectancy of the traumatized primary tooth and vitality of the pulpal tissue. Pulpal treatment alternatives are pulpotomy pulpectomy and extraction (Flores et al. "Guidelines part 1" 2001; Flores et al 2002; Holan & McTigue 2005; Borum & Andreasen 1998; Fried & Erickson 1995).
• Permanent Teeth: Pulpal treatment alternatives are direct pulp capping partial pulpotomy and pulpectomy (start of root canal therapy) (Flores et al. "Guidelines part 3" 2001; Andreasen & Andreasen 2000; Olsburgh Jacoby & Krejci 2002; Cvek 1978).

General Prognosis: The prognosis of crown fractures appears to depend primarily upon a concomitant injury to the periodontal ligament (Andreasen & Andreasen 2000). The age of the pulp exposure extent of dentin exposed and stage of root development at the time of injury secondarily affect the tooth's prognosis (Andreasen & Andreasen 2000). Optimal treatment results follow timely assessment and care.

Crown/Root Fracture

Definition: An enamel dentin and cementum fracture with or without pulp exposure

Diagnosis: Clinical findings usually reveal a mobile coronal fragment attached to the gingiva with or without a pulp exposure. Radiographic findings may reveal a radiolucent oblique line that comprises crown and root in a vertical direction in primary teeth and in a direction usually perpendicular to the central radiographic beam in permanent teeth. While radiographic demonstration often is difficult root fractures can only be diagnosed radiographically (Flores et al. "Guidelines part 1" 2001; Flores et al. "Guidelines part 3" 2001; Flores 2002; Andreasen & Andreasen 2000; Andreasen & Andreasen 1994).

Treatment Objectives: To maintain pulp vitality and restore normal esthetics and function (Tapias et al. 2003)

• Primary Teeth: When the primary tooth cannot or should not be restored the entire tooth should be removed unless retrieval of apical fragments may result in damage to the succedaneous tooth (Flores et al. "Guidelines part 1" 2001; Flores et al. 2002).
• Permanent Teeth: The emergency treatment objective is to stabilize the coronal fragment. Definitive treatment alternatives are to remove the coronal fragment followed by a supragingival restoration or necessary gingivectomy; osteotomy; or surgical or orthodontic extrusion to prepare for restoration. If the pulp is exposed pulpal treatment alternatives are pulp capping pulpotomy and root canal treatment (Flores et al. "Guidelines part 3" 2001; Andreasen & Andreasen 2000; Olsburgh Jacoby & Krejci 2002).

General Prognosis: Although the treatment of crown-root fractures can be complex and laborious most fractured permanent teeth can be saved (Andreasen & Andreasen 2000). Fractures extending significantly below the gingival margin may not be restorable.

Root Fracture

Definition: A dentin and cementum fracture involving the pulp

Diagnosis: Clinical findings reveal a mobile coronal fragment attached to the gingiva that may be displaced. Radiographic findings may reveal 1 or more radiolucent lines that separate the tooth fragments in horizontal fractures. Multiple radiographic exposures at different angulations may be required for diagnosis. A root fracture in a primary tooth may be obscured by a succedaneous tooth (Flores et al. "Guidelines part 1" 2001; Flores et al. "Guidelines part 3" 2001; Flores 2002; Andreasen & Andreasen 2000).

Treatment Objectives: To reposition as soon as possible and then to stabilize the coronal fragment in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity (Andreasen & Andreasen 1994).

• Primary Teeth: Treatment alternatives include extraction of coronal fragment without insisting on removing apical fragment or observation (Flores et al. "Guidelines part 1" 2001; Flores 2002; Holan & McTigue 2005).
• Permanent Teeth: Reposition and stabilize the coronal fragment (Flores et al. "Guidelines part 3" 2001; Andreasen & Andreasen 2000).

General Prognosis: Pulp necrosis in root-fractured teeth is attributed to displacement of the coronal fragment and mature root development (Andreasen & Andreasen 2000; Freely Mackie & Macfarlane 2003). In permanent teeth the location of the root fracture has not been shown to affect pulp survival after injury (Andreasen & Andreasen 2000; Andreasen et al. "Healing of 400 intra-alveolar root fractures. 1. Effects of pre-injury" 2004). Therefore preservation of teeth with root fractures occurring in the tooth's cervical third should be attempted (Andreasen & Andreasen 2000; Andreasen et al. 2004). Young age immature root formation positive pulp sensitivity at time of injury and approximating the dislocation within 1 millimeter (mm) have been found to be advantageous to both pulpal healing and hard tissue repair of the fracture (Cvek Andreasen & Borum 2001; Andreasen et al. "Healing of 400 intra-alveolar root fractures. 1. Effects of pre-injury" 2004; Andreasen et al. "Healing of 400 intra-alveolar root fractures. 2. Effects of treatment" 2004).

Concussion

Definition: Injury to the tooth-supporting structures without abnormal loosening or displacement of the tooth

Diagnosis: Because the periodontal ligament absorbs the injury and is inflamed clinical findings reveal a tooth tender to pressure and percussion without mobility displacement or sulcular bleeding. Radiographic abnormalities are not expected (Flores et al. "Guidelines part 2" 2001; Flores et al. "Guidelines part 4" 2001; Flores 2002; Andreasen & Andreasen 2000; Holan & McTigue 2005; McTigue 2005).

Treatment Objectives: To optimize healing of the periodontal ligament and maintain pulp vitality (Flores et al. "Guidelines part 2" 2001; Flores et al. "Guidelines part 4" 2001; Flores 2002; Andreasen & Andreasen 2000; Holan & McTigue 2005; Andreasen & Andreasen 1994; McTigue 2005; Crona-Larson Bjarnason & Noren 1991)

General Prognosis: For primary teeth unless associated infection exists no pulpal therapy is indicated (Flores 2002). Although there is a minimal risk for pulp necrosis mature permanent teeth with closed apices may undergo pulpal necrosis due to associated injuries to the blood vessels at the apex and therefore must be followed carefully (Andreasen & Andreasen 2000).

Subluxation

Definition: Injury to tooth-supporting structures with abnormal loosening but without tooth displacement

Diagnosis: Because the periodontal ligament attempts to absorb the injury clinical findings reveal a mobile tooth without displacement that may or may not have sulcular bleeding. Radiographic abnormalities are not expected (Flores et al. "Guidelines part 2" 2001; Flores et al. "Guidelines part 4" 2001; Flores 2002; Andreasen & Andreasen 2000).

Treatment Objectives: To optimize healing of the periodontal ligament and neurovascular supply (Flores et al. "Guidelines part 2" 2001; Flores et al. "Guidelines part 4" 2001; Flores 2002; Andreasen & Andreasen 2000; Holan & McTigue 2005; Borum & Andreasen 1998; Fried & Erickson 1995; Soporowski Allred & Needleman 1994; Ravn 1968; Andreasen & Andreasen 1994; McTigue 2005; Crona-Larson Bjarnason & Noren 1991)

• Primary Teeth: The tooth should be followed for pathology.
• Permanent Teeth: Stabilize the tooth and relieve any occlusal interferences. For comfort a flexible splint can be used. Splint for no more than 2 weeks.

General Prognosis: Prognosis is usually favorable (Holan & McTigue 2005; McTigue 2005). The primary tooth should return to normal within 2 weeks (Flores 2002). Mature permanent teeth with closed apices may undergo pulpal necrosis due to associated injuries to the blood vessels at the apex and therefore must be followed carefully (Andreasen & Andreasen 2000).

Lateral Luxation

Definition: Displacement of the tooth in a direction other than axially. The periodontal ligament is torn and contusion or fracture of the supporting alveolar bone occurs (Holan & McTigue 2005; McTigue 2005; Nikoui Kenny & Barrett 2003).

Diagnosis: Clinical findings reveal that a tooth is displaced laterally with the crown usually in a palatal or lingual direction and may be locked firmly into this new position. The tooth usually is not mobile or tender to touch. Radiographic findings reveal an increase in periodontal ligament space and displacement of apex toward or though the labial bone plate (Flores et al. "Guidelines part 2" 2001; Flores et al. "Guidelines part 4" 2001; Flores 2002; Andreasen & Andreasen 2000; Nikoui Kenny & Barrett 2003).

Treatment Objectives

• Primary Teeth: To allow passive repositioning or actively reposition and splint for 1 to 2 weeks as indicated to allow for healing except when the injury is severe or the tooth is nearing exfoliation (Flores et al. "Guidelines part 2" 2001; Flores 2002; Borum & Andreasen 1998; Fried & Erickson 1995; Soporowski Allred & Needleman 1994; Ravn 1968; Andreasen & Andreasen 1994)
• Permanent Teeth: To reposition as soon as possible and then to stabilize the tooth in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. Repositioning of the tooth is done with digital pressure and little force. The tooth may need to be extruded to free apical lock in the cortical bone plate. Splinting an additional 2 to 4 weeks may be needed with breakdown of marginal bone (Flores et al. "Guidelines part 4" 2001; Andreasen & Andreasen 2000; Andreasen & Andreasen 1994; Crona-Larson Bjarnason & Noren 1991; Nikoui Kenny & Barrett 2003).

General Prognosis: Primary teeth requiring repositioning have an increased risk of developing pulp necrosis compared to teeth that are left to spontaneously reposition (Flores 2002). In mature permanent teeth with closed apices pulp necrosis and pulp canal obliteration are common healing complications while progressive root resorption is less likely to occur (Nikoui Kenny & Barrett 2003).

Intrusion

Definition: Apical displacement of tooth into the alveolar bone. The tooth is driven into the socket compressing the periodontal ligament and commonly causes a crushing fracture of the alveolar socket (Holan & McTigue 2005; McTigue 2005; Humphrey Kenny & Barrett 2003).

Diagnosis: Clinical findings reveal that the tooth appears to be shortened or in severe cases it may appear missing. The tooth's apex usually is displaced labially toward or through the labial bone plate in primary teeth and driven into the alveolar process in permanent teeth. The tooth is not mobile or tender to touch. Radiographic findings reveal that the tooth appears displaced apically and the periodontal ligament space is not continuous. Determination of the relationship of an intruded primary tooth with the follicle of the succedaneous tooth is mandatory. If the apex is displaced labially the apical tip can be seen radiographically with the tooth appearing shorter than its contralateral. If the apex is displaced palatally towards the permanent tooth germ the apical tip cannot be seen radiographically and the tooth appears elongated. An extraoral lateral radiograph also can be used to detect displacement of the apex toward or through the labial bone plate. An intruded young permanent tooth may mimic an erupting tooth (Flores et al. "Guidelines part 2" 2001; Flores et al. "Guidelines part 4" 2001; Flores 2002; Andreasen & Andreasen 2000; Humphrey Kenny & Barrett 2003).

Treatment Objectives

• Primary Teeth: To allow spontaneous re-eruption except when displaced into the developing successor. Extraction is indicated when the apex is displaced toward the permanent tooth germ (Flores et al. "Guidelines part 2" 2001; Flores 2002; Borum & Andreasen 1998; Fried & Erickson 1995; Soporowski Allred & Needleman 1994; Ravn 1968; Andreasen & Andreasen 1994).
• Permanent Teeth: To reposition passively (allowing re-eruption to its preinjury position) or actively (repositioning with traction) or surgically and to stabilize the tooth in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. In teeth with immature root formation the objective is to allow for spontaneous eruption. In mature teeth the goal is to reposition the tooth with orthodontic or surgical extrusion and initiate endodontic treatment within the first 3 weeks of the traumatic incidence (Flores et al. "Guidelines part 4" 2001; Andreasen & Andreasen 2000; Andreasen & Andreasen 1994; Crona-Larson Bjarnason & Noren 1991; Humphrey Kenny & Barrett 2003).

General Prognosis: In primary teeth 90% of intruded teeth will re-erupt spontaneously (either partially or completely) in 2 to 6 months (Holan & McTigue 2005; Gondim & Moreira Neto 2005). Even in cases of complete intrusion and displacement of primary teeth through the labial bone plate a retrospective study showed the re-eruption and survival of most teeth for more than 36 months (Holan & Ram 1999). Ankylosis may occur however if the periodontal ligament of the affected tooth was severely damaged thereby delaying or altering the eruption of the permanent successor (Flores 2002). In permanent mature teeth with closed apices there is considerable risk for pulp necrosis pulp canal obliteration and progressive root resorption (Humphrey Kenny & Barrett 2003). Immature permanent teeth that are allowed to reposition spontaneously demonstrate the lowest risk for healing complications (Andreasen Bakland & Andreasen "Traumatic intrusion of permanent teeth. Part 2" 2006; Andreasen Bakland & Andreasen "Traumatic intrusion of permanent teeth. Part 3" 2006). Extent of intrusion (7 mm or greater) and adjacent intruded teeth have a negative influence on healing (Andreasen Bakland & Andreasen "Traumatic intrusion of permanent teeth. Part 2" 2006).

Extrusion

Definition: Partial displacement of the tooth axially from the socket; partial avulsion. The periodontal ligament usually is torn (Holan & McTigue 2005; McTigue 2005; Lee Barrett & Kenny 2003).

Diagnosis: Clinical findings reveal that the tooth appears elongated and is mobile. Radiographic findings reveal an increased periodontal ligament space apically (Flores et al. "Guidelines part 2" 2001; Flores et al. "Guidelines part 4" 2001; Flores 2002; Andreasen & Andreasen 2000; Lee Barrett & Kenny 2003).

Treatment Objectives

• Primary Teeth: To reposition and allow for healing except when there are indications for an extraction (i.e. the injury is severe or the tooth is nearing exfoliation). If the treatment decision is to reposition and stabilize splint for 1 to 2 weeks (Flores et al. "Guidelines part 2" 2001; Flores 2002; Holan & McTigue 2005; Borum & Andreasen 1998; Fried & Erickson 1995; Soporowski Allred & Needleman 1994; Ravn 1968; Andreasen & Andreasen 1994).
• Permanent Teeth: To reposition as soon as possible and then to stabilize the tooth in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity. Repositioning may be accomplished with slow and steady apical pressure to gradually displace coagulum formed between root apex and floor of the socket. Splint for up to 3 weeks (Flores et al. "Guidelines part 4" 2001; Andreasen & Andreasen 2000; Andreasen & Andreasen 1994; Crona-Larson Bjarnason & Noren 1991; Lee Barrett & Kenny 2003).

General Prognosis: There is a lack of clinical studies evaluating repositioning of extruded primary teeth (Flores 2002). In permanent mature teeth with closed apices there is considerable risk for pulp necrosis and pulp canal obliteration (Lee Barrett & Kenny 2003). These teeth must be followed carefully (Flores et al. "Guidelines part 4" 2001; Andreasen & Andreasen 2000).

Avulsion

Definition: Complete displacement of tooth out of socket. The periodontal ligament is severed and fracture of the alveolus may occur (Holan & McTigue 2005; McTigue 2005).

Diagnosis: Clinical and radiographic findings reveal that the tooth is not present in the socket or the tooth already has been replanted. Radiographic assessment will verify that the tooth is not intruded when the tooth was not found (Flores et al. "Guidelines part 2" 2001; Flores 2002; Andreasen & Andreasen 2000; Holan & McTigue 2005; McTigue 2005).

Treatment Objectives

• Primary Teeth: To prevent further injury to the developing successor. Avulsed primary teeth should not be replanted because of the potential for subsequent damage to developing permanent tooth germs. (Flores et al. "Guidelines part 2" 2001; Flores 2002; Andreasen & Andreasen 2000; Holan & McTigue 2005; Ravn 1968; Andreasen & Andreasen 1994).
• Permanent Teeth: To replant as soon as possible and then to stabilize the replanted tooth in its anatomically correct location to optimize healing of the periodontal ligament and neurovascular supply while maintaining esthetic and functional integrity except when replanting is contraindicated by:
  1. The child's stage of dental development (risk for ankylosis where considerable alveolar growth has to take place)
  2. Compromising medical condition
  3. Compromised integrity of the avulsed tooth or supporting tissues

Flexible splinting for 1 week is indicated (Flores et al. "Guidelines part 5" 2001). Tetanus prophylaxis and antibiotic coverage should be considered (Flores et al. "Guidelines part 5" 2001; Andreasen & Andreasen 2000; Andreasen & Andreasen 1994; "Treatment of the avulsed" 1995; Andreasen et al. "Replantation 1" 1995; Andreasen et al. "Replantation 2" 1995; Andreasen et al. "Replantation 3" 1995; Andreasen et al. "Replantation 4" 1995; Barrett & Kenny "Survival" 1997; Barrett & Kenny "Avulsed" 1997).

Treatment strategies are directed at avoiding inflammation that may occur as a result of the tooth's attachment damage and/or pulpal infection (Trope 2002; AAPD 2007).

General Prognosis: Prognosis in the permanent dentition is primarily dependent upon formation of root development and extraoral dry time (Flores et al. "Guidelines part 5" 2001; Andreasen & Andreasen 2000). The tooth has the best prognosis if replanted immediately (Andreasen & Andreasen 1994; Trope 2002). If the tooth cannot be replanted within 5 minutes it should be stored in a medium that will help maintain vitality of the periodontal ligament fibers (AAPD 2002; Sigalas et al. 2004). Transportation media for avulsed teeth include (in order of preference): Viaspan; Hank's Balanced Salt Solution (tissue culture medium); cold milk; saliva (buccal vestibule); physiologic saline; or water ("Treatment of the avulsed" 1995; Andreasen et al. "Replantation 4" 1995; Barrett & Kenny "Survival" 1997; Barrett & Kenny "Avulsed" 1997; Hiltz & Trope 1991). Limited tooth storage in a cell-compatible medium prior to replantation has produced similar healing results as compared with immediately replanted teeth (Pohl Filippi & Kirschner 2005). The risk of ankylosis increases significantly with an extraoral dry time of 15 minutes (AAPD 2002; Chappuis & von Arx 2005). An extra-oral dry time of 60 minutes is considered the point where survival of the root periodontal cells is unlikely (Trope 2002). In permanent avulsed teeth there is considerable risk for pulp necrosis root resorption ankylosis and subsequent infraocclusion during adolescent growth (Andreasen et al. "Replantation 4" 1995; Barrett et al. 2005; Malmgren & Malmgren 2002).

Additional Considerations: There are possible contraindications to tooth replantation. Examples are immunocompromise severe congenital cardiac anomalies severe uncontrolled seizure disorder severe mental disability severe uncontrolled diabetes and lack of alveolar integrity.

Current Research: Antiresorptive-regenerative therapies may have potential for enhancing the prognosis of avulsed teeth (Pohl Filippi & Kirschner 2005). Treatment strategies are directed at avoiding or minimizing inflammation increasing revascularization and producing hard barriers in teeth with open apices (Flores et al. "Guidelines part 5" 2001; Trope 2002; 2003; Trope 2003; Filippi Pohl & von Arx 2001; Finucane & Kinirons 2003; Schjott & Andreasen 2005; Cvek et al. 1990; Maroto et al. 2003; Villa & Fernandez 2005; Rafter 2005; Khin & Sae-Lim 2003; Bryson et al. 2003). Dental practitioners should follow current literature and consider carefully evidenced-based recommendations that may enhance periodontal healing and revascularization of avulsed permanent teeth.

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• American Academy of Pediatric Dentistry. Decision tree for an avulsed tooth. Chicago (IL): American Academy of Pediatric Dentistry; 2007. 1 p.



• American Academy of Pediatric Dentistry. Pediatric dental trauma card--primary teeth permanent teeth. Chicago (IL): American Academy of Pediatric Dentistry; 2002. 2 p.



• Andreasen JO Andreasen FM Mejare I Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex age stage of root development fracture type location of fracture and severity of dislocation. Dent Traumatol 2004 Aug;20(4):192-202. PubMed



• Andreasen JO Andreasen FM Mejare I Cvek M. Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay repositioning splinting type and period and antibiotics. Dent Traumatol 2004 Aug;20(4):203-11. PubMed



• Andreasen JO Andreasen FM. Essentials of traumatic injuries to the teeth. 2nd ed. Copenhagen Denmark: Munksgaard and Mosby; 2000. 9-154 p.



• Andreasen JO Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. Copenhagen Denmark: Munksgaard; 1994. 219-425 750 p.



• Andreasen JO Bakland LK Andreasen FM. Traumatic intrusion of permanent teeth. Part 2. A clinical study of the effect of preinjury and injury factors such as sex age stage of root development tooth location and extent of injury including number of intruded teeth on 140 intruded [trunc]. Dent Traumatol 2006 Apr;22(2):90-8. PubMed



• Andreasen JO Bakland LK Andreasen FM. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay method of repositioning type of splint length of splinting and antibiotics on 140 teeth. Dent Traumatol 2006 Apr;22(2):99-111. PubMed



• Andreasen JO Borum MK Andreasen FM. Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth. Endod Dent Traumatol 1995 Apr;11(2):69-75. PubMed



• Andreasen JO Borum MK Jacobsen HL Andreasen FM. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 1995 Apr;11(2):51-8. PubMed



• Andreasen JO Borum MK Jacobsen HL Andreasen FM. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol 1995 Apr;11(2):59-68. PubMed



• Andreasen JO Borum MK Jacobsen HL Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995 Apr;11(2):76-89. PubMed



• Barrett EJ Kenny DJ Tenenbaum HC Sigal MJ Johnston DH. Replantation of permanent incisors in children using Emdogain. Dent Traumatol 2005 Oct;21(5):269-75. PubMed



• Barrett EJ Kenny DJ. Avulsed permanent teeth: a review of the literature and treatment guidelines. Endod Dent Traumatol 1997 Aug;13(4):153-63. [83 references] PubMed



• Barrett EJ Kenny DJ. Survival of avulsed permanent maxillary incisors in children following delayed replantation. Endod Dent Traumatol 1997 Dec;13(6):269-75. PubMed



• Borum MK Andreasen JO. Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition. Endod Dent Traumatol 1998 Feb;14(1):31-44. PubMed



• Bryson EC Levin L Banchs F Trope M. Effect of minocycline on healing of replanted dog teeth after extended dry times. Dent Traumatol 2003 Apr;19(2):90-5. PubMed



• Chappuis V von Arx T. Replantation of 45 avulsed permanent teeth: a 1-year follow-up study. Dent Traumatol 2005 Oct;21(5):289-96. PubMed



• Crona-Larsson G Bjarnason S Noren JG. Effect of luxation injuries on permanent teeth. Endod Dent Traumatol 1991 Oct;7(5):199-206. PubMed



• Cvek M Andreasen JO Borum MK. Healing of 208 intra-alveolar root fractures in patients aged 7-17 years. Dent Traumatol 2001 Apr;17(2):53-62. PubMed



• Cvek M Cleaton-Jones P Austin J Lownie J Kling M Fatti P. Effect of topical application of doxycycline on pulp revascularization and periodontal healing in reimplanted monkey incisors. Endod Dent Traumatol 1990 Aug;6(4):170-6. PubMed



• Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod 1978 Aug;4(8):232-7. PubMed



• Feely L Mackie IC Macfarlane T. An investigation of root-fractured permanent incisor teeth in children. Dent Traumatol 2003 Feb;19(1):52-4. PubMed



• Filippi A Pohl Y von Arx T. Treatment of replacement resorption with Emdogain--preliminary results after 10 months. Dent Traumatol 2001 Jun;17(3):134-8. PubMed



• Finucane D Kinirons MJ. External inflammatory and replacement resorption of luxated and avulsed replanted permanent incisors: a review and case presentation. Dent Traumatol 2003 Jun;19(3):170-4. [32 references] PubMed



• Flores MT Andreasen JO Bakland LK Feiglin B Gutmann JL Oikarinen K Ford TR Sigurdsson A Trope M Vann WF Jr. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001 Apr;17(2):49-52. PubMed



• Flores MT Andreasen JO Bakland LK Feiglin B Gutmann JL Oikarinen K Ford TR Sigurdsson A Trope M Vann WF Jr. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001 Feb;17(1):1-4. PubMed



• Flores MT Andreasen JO Bakland LK Feiglin B Gutmann JL Oikarinen K Pitt Ford TR Sigurdsson A Trope M Vann WF Jr Andreasen FM. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001 Aug;17(4):145-8. PubMed



• Flores MT Andreasen JO Bakland LK Feiglin B Gutmann JL Oikarinen K Pitt Ford TR Sigurdsson A Trope M Vann WF Jr Andreasen FM. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001 Jun;17(3):97-102. PubMed



• Flores MT Andreasen JO Bakland LK Feiglin B Gutmann JL Oikarinen K Pitt Ford TR Sigurdsson A Trope M Vann WF Jr Andreasen FM. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol 2001 Oct;17(5):193-8. PubMed



• Flores MT. Traumatic injuries in the primary dentition. Dent Traumatol 2002 Dec;18(6):287-98. [84 references] PubMed



• Fried I Erickson P. Anterior tooth trauma in the primary dentition: incidence classification treatment methods and sequelae: a review of the literature. ASDC J Dent Child 1995 Jul-Aug;62(4):256-61. [27 references] PubMed



• Gondim JO Moreira Neto JJ. Evaluation of intruded primary incisors. Dent Traumatol 2005 Jun;21(3):131-3. PubMed



• Hiltz J Trope M. Vitality of human lip fibroblasts in milk Hanks balanced salt solution and Viaspan storage media. Endod Dent Traumatol 1991 Apr;7(2):69-72. PubMed



• Holan G McTigue D. Introduction to dental trauma: managing traumatic injuries in the primary dentition. In: Pinkham JR Casamassimo PS Fields HW Jr. McTigue DJ Nowak A editor(s). Pediatric dentistry: infancy through adolescence. 4th ed. St. Louis (MO): Elsevier Saunders; 2005. p. 236-56.



• Holan G Ram D. Sequelae and prognosis of intruded primary incisors: a retrospective study. Pediatr Dent 1999 Jul-Aug;21(4):242-7. PubMed



• Humphrey JM Kenny DJ Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions. Dent Traumatol 2003 Oct;19(5):266-73. PubMed



• Lee R Barrett EJ Kenny DJ. Clinical outcomes for permanent incisor luxations in a pediatric population. II. Extrusions. Dent Traumatol 2003 Oct;19(5):274-9. PubMed



• Ma KM Sae-Lim V. The effect of topical minocycline on replacement resorption of replanted monkeys' teeth. Dent Traumatol 2003 Apr;19(2):96-102. PubMed



• Malmgren B Malmgren O. Rate of infraposition of reimplanted ankylosed incisors related to age and growth in children and adolescents. Dent Traumatol 2002 Feb;18(1):28-36. PubMed



• Maroto M Barberia E Planells P Vera V. Treatment of a non-vital immature incisor with mineral trioxide aggregate (MTA). Dent Traumatol 2003 Jun;19(3):165-9. PubMed



• McTigue DJ. Managing traumatic injuries in the young permanent dentition. In: Pinkham JR Casamassimo PS Fields HW Jr. McTigue DJ Nowak A editor(s). Pediatric dentistry: infancy through adolescence. 4th ed. St. Louis (MO): Elsevier Saunders; 2005. p. 593-607.



• Nikoui M Kenny DJ Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. III. Lateral luxations. Dent Traumatol 2003 Oct;19(5):280-5. PubMed



• Olsburgh S Jacoby T Krejci I. Crown fractures in the permanent dentition: pulpal and restorative considerations. Dent Traumatol 2002 Jun;18(3):103-15. [71 references] PubMed



• Pohl Y Filippi A Kirschner H. Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy. Dent Traumatol 2005 Apr;21(2):93-101. PubMed



• Rafter M. Apexification: a review. Dent Traumatol 2005 Feb;21(1):1-8. [116 references] PubMed



• Ravin JJ. Follow-up study of permanent incisors with enamel cracks as result of an acute trauma. Scand J Dent Res 1981 Apr;89(2):117-23. PubMed



• Ravn JJ. Follow-up study of permanent incisors with enamel fractures as a result of an acute trauma. Scand J Dent Res 1981 Jun;89(3):213-7. PubMed



• Ravn JJ. Follow-up study of permanent incisors with enamel-dentin fractures after acute trauma. Scand J Dent Res 1981 Oct;89(5):355-65. PubMed



• Ravn JJ. Sequelae of acute mechanical traumata in the primary dentition. A clinical study. ASDC J Dent Child 1968 Jul;35(4):281-9. PubMed



• Robertson A. A retrospective evaluation of patients with uncomplicated crown fractures and luxation injuries. Endod Dent Traumatol 1998 Dec;14(6):245-56. PubMed



• Schjott M Andreasen JO. Emdogain does not prevent progressive root resorption after replantation of avulsed teeth: a clinical study. Dent Traumatol 2005 Feb;21(1):46-50. PubMed



• Sigalas E Regan JD Kramer PR Witherspoon DE Opperman LA. Survival of human periodontal ligament cells in media proposed for transport of avulsed teeth. Dent Traumatol 2004 Feb;20(1):21-8. PubMed



• Soporowski NJ Allred EN Needleman HL. Luxation injuries of primary anterior teeth--prognosis and related correlates. Pediatr Dent 1994 Mar-Apr;16(2):96-101. PubMed



• Tapias MA Jimenez-Garcia R Lamas F Gil AA. Prevalence of traumatic crown fractures to permanent incisors in a childhood population: Mostoles Spain. Dent Traumatol 2003 Jun;19(3):119-22. PubMed



• Treatment of the avulsed permanent tooth. Recommended Guidelines of the American Association of Endodontists. Dent Clin North Am 1995 Jan;39(1):221-5. PubMed



• Trope M. A futuristic look at dental trauma. In: Presentation at the American Academy of Pediatric Dentistry 56th annual session. New York (NY): 2003.



• Trope M. Clinical management of the avulsed tooth: present strategies and future directions. Dent Traumatol 2002 Feb;18(1):1-11. [46 references] PubMed



• Villa P Fernandez R. Apexification of a replanted tooth using mineral trioxide aggregate. Dent Traumatol 2005 Oct;21(5):306-8. PubMed

Type of Evidence supporting the Recommendations

All oral health guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field.

Potential Benefits

• Improved functional and esthetic outcome for children who experience dental trauma
• Improved psychological outlook for such children

Potential Harms

The risk of ankylosis increases significantly with an extraoral dry time of 15 minutes.

Contraindications

• There are possible contraindications to tooth replantation. Examples are immunocompromise severe congenital cardiac anomalies severe uncontrolled seizure disorder severe mental disability severe uncontrolled diabetes and lack of alveolar integrity.
• Replanting is contraindicated by:
  • The child's stage of dental development (risk for ankylosis where considerable alveolar growth has to take place)
  • Compromising medical condition
  • Compromised integrity of the avulsed tooth or supporting tissues

Qualifying Statements

Appendix I of the original guideline document is a sample document for recording assessment of acute traumatic injuries. This sample form developed by the American Academy of Pediatric Dentists (AAPD) is provided as a practice tool for pediatric dentists and other dentists treating children. It was developed by pediatric dentistry experts and offered to facilitate excellence in practice. This form however does not establish or evidence a standard of care. In issuing this form the American Academy of Pediatric Dentists is not engaged in rendering legal or other professional advice. If such services are required competent legal or other professional counsel should be sought. Well-designed follow-up procedures are essential to diagnose complications.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms
Resources

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Getting Better

IOM Domain

Effectiveness
Safety

Bibliographic Source(s)

• American Academy of Pediatric Dentistry (AAPD). Guideline on management of acute dental trauma. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2007. 14 p. [81 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Academy of Pediatric Dentistry

Guideline Committee

Council on Clinical Affairs

Composition of Group that Authored the Guideline

The Council on Clinical Affairs and Council on Scientific Affairs are comprised of pediatric dentists representing the six geographical districts of the American Academy of Pediatric Dentistry (AAPD) along with additional consultants confirmed by the Board of Trustees.

Financial Disclosures/Conflicts of Interest

Council members and consultants were asked to disclose potential conflicts of interest. None was identified.

Guideline Status

This is the current release of the guideline.

It updates a previously published version: American Academy of Pediatric Dentistry. Clinical guideline on management of acute dental trauma. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 8 p.

Guideline Availability

Electronic copies: Available from the American Academy of Pediatric Dentistry Web site.

Print copies: Available from the American Academy of Pediatric Dentistry 211 East Chicago Avenue Suite 700 Chicago Illinois 60611.

Availability of Companion Documents

Information about the American Academy of Pediatric Dentistry (AAPD) mission and guideline development process is available on the AAPD Web site.

The following implementation tool is available for download from the AAPD Web site:

• Dental growth and development chart

Additionally a sample implementation tool for recording assessment of acute traumatic injuries is included in Appendix I in the original guideline document.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on March 16 2005. The information was verified by the guideline developer on April 18 2005. This summary was updated by ECRI Institute on April 3 2008. The updated information was verified by the guideline developer on April 30 2008.

COPYRIGHT STATEMENT

This summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

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