Survival analysis of fragment reattachments and direct composite restorations in permanent teeth after dental traumatic injuries.

BACKGROUND/AIM: In case of crown fractures after traumatic dental injuries, the affected teeth can be restored either with reattachment of the fractured fragment or with a direct composite restoration. So far, longevity data for reattachments and direct composite restorations with regard to different failure types (pulp necrosis and infection, restoration loss) are scarce. Therefore, the aim of this retrospective study was to evaluate the restorative and biological survival of reattached fragments and composite restorations after crown fractures in permanent teeth. MATERIAL AND METHODS: Dental records of patients treated between 2000 and 2018 were retrospectively analysed regarding the restoration (reattachment or direct composite restorations) of teeth with crown fractures. Survival (no further intervention) and restorative and/or biological failure of all restored teeth were recorded. Statistical analysis was performed using Kaplan-Meier statistics, and the mean annual failure rates for two and 5 years were calculated. Furthermore, the effect of potential risk factors on survival was assessed. Log-rank tests and univariate Cox regression models (likelihood ratio tests) were used to assess the univariate effect of all variables of interest. Variables with a p-value ≤.10 were included in a multivariate Cox regression model with shared frailty (p < .05). RESULTS: Overall, 164 patients with 235 teeth (uncomplicated crown fracture: N = 201, complicated crown fracture: N = 34) were included (1.6 ± 2.5 years observation time). Of these, 59 teeth were restored with reattachment of the fragment and 176 with a composite restoration. Overall, composite restorations had a significantly higher survival rate than reattachments (p = .002). The cumulative survival after 2 years was 42.9% and 65.0% for teeth treated with a reattachment (mAFR = 34.5%) and a composite restoration (mAFR = 19.3%), respectively. When differentiating between failure types, restoration failure and pulp necrosis were significantly more frequently detected in reattached crown fractures compared to composite restorations (restorative failure: p = .001; biological failure: p = .036). In the multivariate Cox regression model, the variable jaw and luxation significantly influenced the survival when the tooth was restored with a composite restoration. The survival was not influenced by the fracture type. CONCLUSIONS: Restorative and biological failures were more frequently detected when the tooth was restored with a reattached fragment compared to a direct composite restoration. Both, restoration failure and pulp necrosis with infection should be considered as frequent complications after restoration of crown-fractured teeth which emphasizes the necessity of regular and short follow-up intervals throughout the first 2 years.

Critical appraisal of the 2020 IADT Guidelines: A personal commentary.

The 2020 International Association of Dental Traumatology (IADT) Guidelines feature several important changes in the treatment recommendations for traumatic dental injuries (TDIs) from the previous 2012 iteration of these Guidelines. This evidence-based narrative review aims to provide a detailed appraisal of five specific changes incorporated in the 2020 IADT Guidelines, based on the available literature evidence that may have prompted these changes. The paper discusses three excellent additions/changes to the new Guidelines: (i) inclusion of a core outcome set for reporting TDIs; (ii) more conservative management of primary dentition TDIs including the changed recommendations for radiation exposure and managing primary dentition luxation injuries; and (iii) the changes in the treatment recommendations for permanent dentition avulsion injuries. The paper further debates whether two other changes made in the current IADT Guidelines for-(i) intrusion injuries in immature teeth; and (ii) complicated crown-root fractures in mature teeth-have sufficient evidence to support the changed recommendations.

Conservative management of a horizontal root fracture in a primary maxillary central incisor: Case report.

Dental trauma occurs frequently in toddlers and the treatment protocols vary depending on each case. Thus, clinicians must not only plan the treatment but also consider any possible sequelae and characteristics related to the child and the family. The aim of this paper was to report a case of a three-year-old boy who had a horizontal root fracture in the middle third of the primary maxillary right incisor root (tooth 51) and crown discoloration of the primary maxillary left incisor (tooth 61) which were successfully treated with conservative management. The management was established in agreement with the family and was based on active surveillance. The clinical and radiographic follow-ups showed no changes besides pulp canal calcification of the left incisor throughout the eight years of follow-up. The pulps remained normal with no pathological signs throughout their life cycle and the permanent successors erupted normally, presenting an excellent result of the non-invasive approach adopted.

Impact of crown fracture treatment on oral health-related quality of life of children, adolescents, and their families: A prospective clinical study.

BACKGROUND: Enamel-dentin fracture causes impact on the oral health-related quality of life (OHRQoL) of children. AIM: To evaluate the impact of treatment of crown fracture involving enamel and dentin (CFED) in the permanent dentition on the OHRQoL of children and adolescents (C/As) and their families. DESIGN: This prospective clinical study included C/As between 8 and 14 years who presented anterior CFED treated thought direct composite resin restoration. Their parents/caregivers (P/Cs) were also invited to take part of the study. The quality of life was evaluated thought the Child Perceptions Questionnaires (CPQ8-10  and CPQ11-14 ), Parental-Caregiver Perceptions Questionnaire (P-CPQ), and Familiar Impact Scale (FIS), applied before and 3 months after the restorative procedure. T test for dependent samples and Wilcoxon test were applied(P < 0.05). RESULTS: Of 32 C/As included, 30 completed the study. The treatment of CFED reduced the negative impact in OHRQoL of C/As (CPQ8-10 P = 0.0065; CPQ11-14 P = 0.0486; P-CPQ, P = 0.0259), specially for "oral symptoms" (CPQ8-10 , P = 0.0003; P-CPQ, P = 0.0455) and "emotional well-being" (CPQ11-14 , P = 0.0431). Concerning the families' perceptions, the treatment did not influence OHRQoL both in terms of the domains and total FIS score (P > 0.05). CONCLUSION: Restorative treatment of CFED increases the OHRQoL of C/As but not influence the OHRQoL of their families.

Periodontal status of anterior teeth following clinical crown lengthening by minimally traumatic controlled surgical extrusion.

BACKGROUND/AIMS: The number of fractured anterior teeth following trauma has been increasing while not every patient is able to afford a dental implant instead of maintaining the injured tooth. Thus, a tooth conservation solution is required to place an aesthetic and functional restoration without biologic width violation. The aim of this study was to evaluate the effectiveness of minimally traumatic controlled surgical extrusion in fractured anterior teeth crown lengthening by assessing the periodontal status through clinical examination and radiographs. METHODS: This longitudinal observational study investigated a group of 18 patients (six males and 12 females) at the Department of Periodontology, National Hospital of Odonto-stomatology, Ho Chi Minh City, Vietnam. Following pre-surgery procedures and examination, minimally traumatic controlled surgical extrusion was carried out using a periotome. Patients were examined at four follow-up appointments after 1 week, 1, 3 and 6 months to record the following experimental variables: periodontal parameters including the gingival index (GI), pocket depth (PD), bleeding on probing (BOP), mobility, marginal gingiva position, alveolar ridge resorption, periapical osteogenesis, tooth resorption and ankylosis. RESULTS: All periodontal parameters were significantly decreased at 3 and 6 months post-procedure (P < 0.001). Tooth mobility decreased gradually following surgery, and at 6 months, all teeth became normal at level 0. Periapical osteogenesis changes were significantly increased at 1, 3 and 6 months in comparison with pre-surgery (P < 0.001). Marginal gingiva position and alveolar ridge resorption were not significantly different between pre-surgery and 1, 3 and 6 months post-surgery. No cases of root resorption or ankylosis were observed at 6 months post-surgery. CONCLUSION: A minimally traumatic controlled surgical extrusion technique for clinical crown lengthening yielded highly successful results in both aesthetic and functional aspects, and no cases had unfavourable outcomes during the 6-month follow-up period.

The impact of crown fracture in the permanent dentition on children's quality of life.

BACKGROUND/AIM: Among the diseases related to oral health, traumatic dental injuries (TDI) can lead to pain, loss of function and aesthetic problems, with physical, emotional and social consequences for children and their families. The aim of this study was to investigate the relationship between enamel fracture and enamel-dentin fracture with oral health-related quality of life (OHRQoL). MATERIAL AND METHODS: This cross-sectional study had a representative sample of 1589 children between 8-10 years of age from public schools. The OHRQoL was obtained through the Child Perceptions Questionnaire (CPQ8-10 ), which is a questionnaire validated for Brazilian children. Clinical data were collected by 4 calibrated examiners (Kappa > 0.7) using the Decay, Missing, Filled Teeth (DMFT) Index, Dental Aesthetic Index (DAI) and TDI. A socio-economic questionnaire was sent to the caregivers to be answered at home. Descriptive statistics and Poisson regression with prevalence ratio (PR) and 95% confidence interval (CI) were used for statistical analysis. RESULTS: The prevalence of TDI was 10.6%, and among these 10.3% who had an impact on the OHRQoL, it was due to enamel-dentin fracture. Children with enamel-dentin fracture had (PR 1.35; 95% CI 1.07-1.70) higher prevalence of impact on the OHRQoL. Children with enamel fracture had no impact on the OHRQoL (P = .254). CONCLUSION: Enamel fracture had no significant impact on children's quality of life, while enamel-dentin fracture did have an impact on quality of life.

Combined orthodontic, surgical, and restorative approach to treat a complicated crown-root fracture in a maxillary central incisor.

This case report shows the treatment of a severe traumatic tooth injury. For the maxillary right central incisor, the trauma was considered a complicated crown-root fracture. The level of the fracture line, the length of the remaining root segment, and the presence and condition of the tooth fragment determined the type of therapy. Traumatized teeth with fractures below the alveolar crest are often considered hopeless. As this report shows, the treatment of a complicated crown-root fracture in the esthetic region can be challenging. Orthodontic extrusion and crown-length surgery were performed to bring the fracture line above the alveolar bone crest. A multidisciplinary approach was required for complete rehabilitation of the traumatized maxillary incisor. Suggestions are made to improve treatment planning of complicated crown-root fractures.

Timely management of knocked out teeth - are the nurses aware?

AIMS AND OBJECTIVES: To assess working and trainee nurses' knowledge and awareness regarding the emergency handling of traumatic injuries to the teeth. The research was conducted in four different parts of Karnataka, a state in India. BACKGROUND: Traumatic injuries to teeth and the facial region are common among children and young adults. Most traumatic dental injuries can be avoided, or would be less serious, if an extensive knowledge and awareness of these injuries existed, especially among people who frequently come across them. DESIGN: The study is a cross-sectional, questionnaire-based survey conducted among nurses of Karnataka. METHODS: The questionnaire was given to nurses in different parts of Karnataka, India. Six hundred and two nurses completed a 15-item questionnaire, assessing their knowledge and practices in the management of traumatic injuries to the teeth. RESULTS: Most of the nurses knew that an avulsed tooth can be replaced in the socket and approximately 70% knew mouthguards and other protective measures are available. The nurses' knowledge was, however, inadequate given their exposure to emergency cases and this was borne out by the fact that the study subjects reported that they require still more adequate training in emergency handling of dental injuries. CONCLUSION: This study reveals that nurses in the current study have less knowledge than expected. Sufficient training should be provided, not only to doctors and dentists in emergency departments, but also to paramedical technicians and nurses to ensure proper care and appropriate advice is available to parents of children experiencing dental trauma. Hence, this study recommends an extensive health education programme in this field. RELEVANCE TO CLINICAL PRACTICE: As nurses play a vital role in the emergency dental services provided to patients, the importance of dental injury and its emergency management must be included in their curriculum.

An Innovative Method for Fragment Reattachment after Complicated Crown Fracture.

The case of a nineteen-year-old female with atypical fractures to three maxillary incisors (#11 FDI, #8 universal; #21 FDI, #9 universal and #22 FDI, #10 universal) with one showing a complicated crown fracture and pulp exposure is reported. A partial pulpotomy had been carried out immediately after trauma and the patient complained of acute pain on percussion of the left central incisor. Direct restoration with resin-based composite was carried out on the two teeth where fragments were not available (tooth #8 and #10) and root canal treatment with reattachment of fragments and fiber post was carried out on the third (tooth #9). An innovative method was used to reattach the tooth fragments whereby the fiber post was inserted without drilling a hole in the crown thus preserving the integrity of the crown. Follow-up visits confirmed the success of treatment based on clinical and radiographic evaluations. The patient was pain free with no tooth sensitivity and good function and esthetics after four years of follow-up. CLINICAL SIGNIFICANCE: Case report with a follow-up of 4 years, provides confirmatory evidence of the long-term efficacy of an innovative method to reattach tooth fragments whereby fiber post is inserted without drilling a hole in the crown thus preserving the integrity of the crown. (J Esthet Restor Dent 29:172-177, 2017).

Management of an uncomplicated crown fracture by reattaching the fractured fragment-Case report.

Coronal fractures of the anterior teeth are common sequelae of traumatic dental injuries. Reattachment of fractured tooth fragments using dental adhesive techniques offers some advantages, including restoration of the function, esthetics, shape, texture, and brightness of the surface. The present report describes a clinical case of reattachment with a 4-year clinical and radiographic follow up in a permanent maxillary central incisor with an uncomplicated crown fracture. Fragment reattachment is a conservative procedure, preserving esthetics and functionality, and it can provide an immediate positive emotional response from the patient.

Pulp prognosis following conservative pulp treatment in teeth with complicated crown fractures-A retrospective study.

BACKGROUND/AIM: Complicated crown fractures are relatively common in children where the maintenance of the pulp is especially important in young permanent teeth. The aim of this study was to analyze the pulp prognosis of permanent teeth with complicated crown fractures treated with conservative pulp treatment in adolescents. MATERIAL AND METHODS: Complete dental records of teeth with complicated crown fractures treated with conservative pulp treatment were obtained. The risk of pulp necrosis and infection was evaluated by the Kaplan-Meier method and Cox regression (P<.05). Risk factors included gender, age, time interval between dental injury and treatment, stage of root development, type of pulp treatment, and coronal restoration. RESULTS: The study involved 375 teeth treated with direct pulp capping, partial or coronal pulpotomy, and direct pulp capping retreated by pulpotomy (partial or coronal). The frequency of pulp necrosis and infection was 10.1% (11/109) for partial pulpotomy and 9.8% (22/205) for coronal pulpotomy. There was no difference between partial and coronal pulpotomy (P=.673). The risk of pulp necrosis and infection was not significantly different between pulpotomy (partial and coronal; 33/314, 10.5%) and retreatment by pulpotomy (partial or coronal) after direct pulp capping (2/33, 6.1%; P=.436). However, the frequency of pulp necrosis and infection after direct pulp capping (16/28, 57.1%) was significantly higher than that with pulpotomy (partial or coronal; odds ratio=8.216, P<.001). The time interval between dental injury and treatment did not significantly influence pulp survival after pulpotomy (partial or coronal; P=.312), but the stage of root development had a significant impact (P<.001). CONCLUSIONS: Partial or coronal pulpotomy, employed either as a primary pulp treatment or secondary to emergency pulp capping, had similarly satisfactory pulp survival rates.

The Influence of Force Direction on the Fracture Pattern and Fracture Resistance of Canine Teeth in Dogs.

Biomechanical studies of the elongated canine tooth of animals are few, and thus our understanding of mechanical and physical properties of animal teeth is limited. The objective of the present study was to evaluate the influence of force direction on fracture resistance and fracture pattern of canine teeth in an ex vivo dog cadaver model. Forty-five extracted canine teeth from laboratory beagle dogs were standardized by hard tissue volume and randomly distributed among 3 force direction groups. The teeth were secured within a universal testing machine and a load was applied at different directions based on testing group. The maximum force to fracture and the fracture pattern classification were recorded for each tooth. After correcting for hard tissue cross-sectional area in a multivariate analysis, no significant difference in the amount of force required for fracture was apparent between the different force direction groups. However, the influence of force direction on fracture pattern was significant. The results of this study may allow the clinician to educate clients on possible causal force directions in clinically fractured teeth and, thus, help prevent any contributing behavior in the future.

MTA Pulpotomies: A Long-Term Case Series Outcomes Assessment of Complicated Crown Fractures.

BACKGROUND: This retrospective case series describes the outcomes of anterior teeth with complicated fractures treated using mineral trioxide aggregate (MTA) in pulpotomy procedures. METHODS: 33 teeth were treated with MTA pulpotomy procedures in an endodontic private practice. All patients had been referred to the practice for diagnosis and treatment of a pulpal exposure due to complicated crown fractures. The teeth were either recalled directly or "indirectly" by the referring dentist. Teeth recalled directly were categorized as healed, healing, non- surgical root canal treatment completed for either aesthetic or restorative reasons, or persistent disease. Teeth recalled indirectly were categorized as successful or failed. RESULTS: 27 teeth were available for recall; 20 teeth directly and 7 teeth indirectly. The mean recall for teeth recalled directly was 3.94 years and the mean recall for teeth recalled indirectly was 5.9 years. The recall range for teeth recalled directly was 0.51 to 10.49 years and for teeth recalled indirectly was 3.58 to 10.66 years. Of the cases available for direct recall, 13 of 20 teeth were healed positive to pulp tests, 4 of 20 teeth were healed negative to pulp tests and 3 of 20 teeth had non-surgical root canal treatment completed. 15 of the 20 teeth recalled directly where discolored. 7 of 7 teeth recalled indirect were successful as determined by the radiographs and a report from the restorative dentist. CONCLUSIONS: MTA is a viable alternative to calcium hydroxide for pulpotomies.

Trends in the prevalence of traumatic crown injuries and associated factors in Brazilian preschool children: 10-year observational data.

OBJECTIVE: To assess trends in the prevalence of traumatic crown injuries (TCI) in children aged 1-4 years living in Diadema city (Brazil) and to investigate whether TCI were associated with socio-demographic and clinical variables. METHODS: Six cross-sectional surveys with representative samples were carried out from 2002 to 2012 following the same criteria and methodology. A total of 6389 children were evaluated and systematically selected on the National Children's Vaccination day. Calibrated examiners performed the children's oral examination for TCI according to Andreasen's criteria. Chi-square test for trends was used to perform comparative analysis. Poisson regression was used to associate TCI to socio-demographic and clinical variables. RESULTS: The prevalence of TCI in 2002 for preschool children aged 1, 2, 3 and 4 years was 4.5%, 11.4%, 14% and 13.9%, respectively, and the prevalence in 2012 for the same age groups was 10.4%, 15.9%, 25.7% and 28.1%, respectively. There was a significant increase in the prevalence of TCI for all age groups and for the total sample (P < 0.05). Children's age was associated with TCI in all the surveys. Male gender, presence of anterior open bite and inadequate lip coverage were associated with TCI in some surveys along the years (P < 0.05). CONCLUSION: This study has shown an increase of TCI prevalence in Brazilian preschool children in the last 10 years and its association with children's age, male gender, presence of anterior open bite and inadequate lip coverage. However, this increase does not seem to be relevant to decisions on public policy.

Restoring crown fractures by direct composite layering using transparent strip crowns.

Traumatic dental injuries are mostly seen at childhood and adolescence. The most common fracture in permanent anterior teeth is crown fracture. Esthetic and easy rehabilitation of these anterior teeth is possible using layering techniques and direct composite resin restorations. Shape, color and surface texture are the most important factors in restoring crown fractures esthetically. This article illustrates how to perform an esthetic composite resin restoration of crown fractures using strip crowns. The technique suggests using a strip crown as a mold for direct resin composite restoration. This provides a cost-effective treatment with operator friendly approach where most outstanding advantage is the minimum chair-side time with a single visit that is very important for young trauma patients.

Cross-sectional Study of Dental Trauma and Associated Factors Among 9- to 14-year-old Schoolchildren in Isfahan, Iran.

PURPOSE: To assess the prevalence of dental trauma (DT) and its associated factors in 9- to 14-year-olds. SUBJECTS AND METHODS: A cross-sectional survey was carried out through clinical examination of the permanent incisors and canines of 907 schoolchildren (9 to 14 years old, average age = 11 ± 0.5 [SD] years, 55% female and 45% male) enrolled in 20 public schools in Isfahan, Iran. The demographic data, history and cause of trauma were recorded during patient interviews and with a structured questionnaire filled in by their parents. The overjet, lip coverage, and visible signs of DT (permanent incisors only, similar to the classification used by the US National Health and Nutrition Examination Survey 1988-1994, NHANES III) were recorded. DT in permanent canines were also recorded. RESULTS: Approximately 36% (n = 325) recalled the occurrence of dental trauma, but only 23.8% (n = 216) of children had visible signs of dental trauma to the permanent incisors (girls [18.8%], boys [29.9%], OR = 0.54; 95% CI 0.40- 0.74; p = 0.000). The maxillary central incisors were commonly injured (69.5%). The most frequent types of injuries were the enamel fracture (59.0%), craze lines (16.3%), and enamel and dentin fracture (13.4%). Tooth avulsion was seen in 0.7%. No significant association was found between dental trauma and increased overjet of > 3 mm (p = 0.328), but a tendency was identified for overjet > 5 mm (OR = 1.51; 95% CI 0.89-2.58; p = 0.060). The relationship between DT and lip coverage was statistically significant (OR = 1.63; 95% CI 1.18-2.25; p = 0.003). Violence (30%) and fall (22.7%) were the main causes of DT. CONCLUSION: The prevalence of DT in permanent incisors was high (23.8%) and significantly lower in girls. The association between DT and lip coverage was significant. There was no association between DT and increased overjet of > 3 mm.

Prevalence and family structures related factors associated with crown trauma in school children resident in suburban Nigeria.

BACKGROUND: Multiple risk factors have been identified for traumatic dental injuries, including crown fractures, in various age groups and various populations. The objective of this study was to determine the prevalence, risk factors and family related factors for crown trauma among 8 to 16 year-old children in a suburban population, Nigeria. METHODS: This is a secondary analysis of a data of 2107 children collected through a school-based survey. Study participants were 8 to 16 year-old resident in suburban Nigeria. The independent variables for the study were age, sex, socioeconomic status, and birth rank, family size and parenting status (one parent, step parent, both parents, and guardians). Details were collected using an interviewer administered questionnaire. Intraoral examination was conducted to identify presence of crown fracture. The independent variables associated with and predictors of crown trauma were determinedusing chi-square and logistic regression analysis respectively. RESULTS: Only 167 (7.9 %) of the 2107 study participants had crown trauma. The teeth level prevalence of crown trauma was 0.33 %. Children with middle socioeconomic status had reduced odds of having crown trauma when compared with children with low socioeconomic status (AOR 0.50; CI 0.32-0.80). The odds of having crown traumawas more than doubled in males when compared with females (AOR 2.41; CI 1.72-3.39) and almost doubled in children living with single parents when compared with children living with both parents (AOR 1.94; CI 1.29-3.05). CONCLUSIONS: The prevalence of crown traumawas low in this study population. Being a female and having lowsocioeconomic status significantly reduced the risk factors for crown traumawhile living with single parents increased risk for crown trauma.

Crown-root Fracture Restoration on a Patient with Autism Spectrum Disorder.

INTRODUCTION: Children with intellectual and physical disabilities including autism are susceptible to dental trauma as a sequela from falls due to poor muscular coordination. In addition, their altered muscle tonus often results in an open bite with labial flaring of the maxillary incisors and lip incompetence, predisposing these teeth to fractures. This case report describes an alternative approach of restoring a fractured maxillary permanent central incisor with a composite strip crown during surgical repositioning of the periodontium on an autistic patient. The prognosis of the incisor is guarded due to the probability of re-injury. However, the decision to maintain the tooth clinically was esthetically preferable in comparison to an extraction or decoronation.

Partial Pulpotomy with BioAggregate in Complicated Crown Fractures: Three Case Reports.

This report describes three cases of complicated crown fractures treated with partial pulpotomy using BioAggregate. Three maxillary permanent central incisors with complicated crown fracture were treated by partial pulpotomy using BioAggregate and reviewed clinically and radiographically for 24 months. Throughout this period, there was no spontaneous pain, periapical radiolucency, and coronal discoloration; the pulp was observed to be vital. Based on these findings, it was concluded that BioAggregate can be used in partial pulpotomy treatment of complicated crown fracture.

Orthodontic Treatment of Maxillary Incisors with Severe Root Resorption Caused by Bilateral Canine Impaction in a Class II Division 1 Patient.

This case report shows the successful alignment of bilateral impacted maxillary canines. A 12-year-old male with the chief complaint of the protrusion of his maxillary anterior teeth happened to have bilateral maxillary canine impaction on the labial side of his maxillary incisors. Four maxillary incisors showed severe root resorption because of the impacted canines. The patient was diagnosed as skeletal Class II malocclusion with proclined maxillary incisors. The impacted canine was carefully retracted using sectional buccal arch wires to avoid further root resorption of the maxillary incisors. To distalize the maxillary dentition, two palatal miniscrews were used. After 25 months of treatment, the maxillary canines were well aligned without any additional root resorption of the maxillary incisors.