Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent Teeth.

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent Teeth.

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

Implant-supported mandibular overdentures and cortical bone formation: clinical and radiographic results.

PURPOSE: The aim of this study was to evaluate the hard and soft tissue parameters around implants supporting overdentures and the possible influence of increased periimplant bone density (IPBD) on implant success. MATERIALS AND METHODS: A total of 44 dental implants placed in the mandible of 12 patients were included in the study. Implants were divided in 2 groups in relation to the optically detected IPBD. Periimplant clinical and radiographic variables were collected over the period of 5 years. RESULTS: Periimplant clinical and radiographic parameters for all implants did not change significantly throughout the observation period (P > 0.05). Significant differences were observed between implants with and without IPBD for periimplant soft tissue parameters and Periotest values (P < 0.05). Implants with and without IPBD at 5-year control showed mean bone loss of 0.04 ± 0.48 mm and 0.55 ± 0.96 mm, respectively (P = 0.026). All density values decreased throughout the observation period, except maximal values for implants with IPBD that overcome the initial values at the 5-year control. CONCLUSIONS: Implants supporting overdentures were clinically successful over the period of follow-up. IPBD may be related to the maintenance of the periimplant bone level.

Clinical and radiographic outcome of dental implants supporting fixed prostheses: the relevance of cortical bone formation.

PURPOSE: To evaluate the hard and the soft tissue parameters around implants supporting fixed prostheses over a period of 5 years and the possible association to the increase in periimplant bone density (IPBD). MATERIAL AND METHODS: A total of 39 dental implants placed in 29 patients were included in the study. Periimplant clinical (gingival index, probing depth, keratinized mucosa, sulcus fluid flow rate) and radiographic variables (bone loss, bone density) were collected, and the data analysis performed. RESULTS: Periimplant hard and soft tissue parameters remained stable throughout the follow-up period. Of the 39 implants, 20 demonstrated IPBD. The mean distance between first bone-to-implant contact and the microgap for implants with and without IPBD was significantly different at 1-year, 2-year, and 5-year follow-up. The evidence of IPBD demonstrated no influence on the periimplant soft tissue parameters. All mean values of bone density for implants with IPBD were higher than those for implants without IPBD throughout the whole observation period. CONCLUSION: All implants were clinically successful over the period of follow-up. IPBD might be more indicative of a stable periimplant bone level.

International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth.

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

Traumatic dental injuries in twins: is there a genetic risk for dental injuries?

Traumatic dental injuries are a major cause of morbidity among children. Investigation of risk factors of dental trauma is important to take preventive measures in patients at high risk for tooth accidents. The aim of this work was to conduct a pilot study in twins, assessing concordance of suffered traumatic dental and facial injuries. Comparison of concordances between monozygotic and dizygotic twin pairs was performed in order to investigate possible genetically determined accident-proneness. Standardized interviews were conducted focusing on the frequency of orofacial accidents and their circumstances. In addition, the front teeth of all participating twins were clinically examined. A total of 104 twins (52 twin pairs) were surveyed: 31 of the 52 twin pairs were DZ and 21 pairs were MZ. 36 (34.6%) of the 104 interviewees had already suffered from a tooth injury, whereas 53 (51%) of the participants had experienced a facial injury. Investigation of concordances of suffered traumatic dental injuries revealed that 66.7% of the MZ twin pairs and 58.1% of the DZ pairs were concordant. With respect to facial traumata, 52.4% of the MZ pairs compared to 58.1% of the DZ pairs were concordant. Differences between zygosity were not statistically significant (P >/= 0.05). With the present pilot study, no statistical evidence of genetic risk for dental and facial injuries could be displayed. On the contrary, environmental factors seem to dominate in determining an individual's risk for orofacial traumata.

Dental injuries in mountain biking--a survey in Switzerland, Austria, Germany and Italy.

Mountain biking is considered an extreme sport, causing not only head and neck injuries, but also injuries to every part of the body. Using standardised interview, the aim of this work was to survey the frequency of dental injuries in mountain biking, as well as the behaviour of athletes after experiencing dental trauma, depending on their intensity level. Furthermore, habits of wearing helmets and mouthguards as well as knowledge about the tooth rescue kit were investigated. A total of 423 male mountain bikers from Germany, Italy, Austria and Switzerland were surveyed for this study, including 50 juniors from Switzerland. 27 athletes (5.7%) had endured tooth accidents in mountain biking. Only 246 (52%) were aware of the fact that avulsed teeth can be replanted, and only 30 individuals knew about the tooth rescue kit (6.3%). 71.9% (n=340) were familiar with mouthguards; however, only 21 individuals (4.4%) used mouthguards while mountain biking. The results show that where mountain biking is concerned, more information about prevention is required.

Transplantation of primary canines after loss or ankylosis of upper permanent incisors. A prospective case series study on healing and survival.

Primary canines were transplanted to replace lost or ankylosed permanent upper incisors. Healing, healing complications and loss and survival were evaluated in a prospective case series study. In total, 27 primary canines were transplanted. Extraorally posts made of titanium were inserted into the root canal from a retrograde direction as an immediate endodontic treatment and as an elongation of the short autologous roots. In some cases antiresorptive-regenerative therapy was used. Inclusion criteria for the evaluation were a minimal observation period of 12 months or the observation of complications. The median observation period of the analyzed 17 transplants was 26.6 months (min: 6.7 months, max: 54.6 months). Sixteen out of seventeen transplants exhibited functional healing until the end of the observation or the occurrence of an external influence (another trauma, resorption by neighbored tooth). In no case ankylosis or arrest of alveolar growth was recorded. In some transplants resorptions not related to infection or ankylosis were observed. One transplant exhibited an early infection-related complication and was removed. One transplant was resorbed by the developing permanent canine and lost. Following another trauma five transplants were lost. External influence and new trauma were significantly related to the loss of transplants (Fisher's exact test; P = 0.0006 and 0.0034). The estimated survival according to a Kaplan-Meier analysis was 40.7 months for all transplants. It was significantly shorter for teeth which were lost in relation to an external influence (survival 28.4 months vs 44.7 months; log rank test: P = 0.0093). The transplantation of primary canines maintains bone and soft tissues of the alveolar process. The healing rate is high. However, there is a high incidence of repeated trauma episodes, causing a high loss rate. The observation period is still limited.

Practicability of a tooth rescue concept--the use of a tooth rescue box.

Healing following replantation of avulsed teeth is dependent upon short unphysiologic periods during the extraalveolar phase. A commercially available tooth rescue box was developed and distributed at schools in Hessen, a state in Germany. Aim of the study was to evaluate the availability times of rescue boxes and the storage periods of rescued teeth within the boxes. Two thousand one hundred tooth rescue boxes together with a questionnaire were distributed predominantly at schools. In case of usage of a box, the questionnaire should be filled out by patients and dentists and sent back for evaluation. One hundred seventy-two (8.2%) questionnaires were sent back. Eighteen questionnaires were incomplete. In the remaining 154 tooth rescue boxes, a total of 201 avulsed teeth and tooth crown fragments were rescued. When accidents occurred near a stored rescue box, the availability time was short (median: 5 min). It was significantly longer (median: 35 min) when the location of the accident was distant to a stored box. Storage of avulsed teeth in the tooth rescue box was longer (median: 2 h) than storage of fractured crown fragments (median: 1 h). Lay people (teachers, pupils) used the rescue boxes correctly without professional help or even advice through telephone. The usage of the tooth rescue box seemed to be self-explanatory and plausible to lay persons, very short availability times resulted when accidents occurred near stored boxes. Thus, an excellent healing prognosis can be anticipated after replantation. The storage periods of avulsed teeth before the commencement of treatment exceed by far the periods that are acceptable for alternative but unphysiologic media (saline, saliva, milk). It is concluded that tooth rescue boxes should be distributed at locations prone to tooth traumas (schools, kindergartens, sporting facilities, public pools) to enhance the prognosis of avulsed teeth. Emergency units (hospitals, ambulances) should be equipped with tooth rescue boxes as well as every dentist. Tooth rescue boxes are recommended for families with children.

Displaced premolars in panoramic radiography: fact or fallacy?

OBJECTIVE: To test the null hypothesis that there is no difference between premolar position visualized on panoramic radiographs (PRs) and lateral headfilms (LHs). MATERIALS AND METHODS: The prevalence of differences in the direction of crown angulation between PR and LH was assessed. Furthermore, brass wire markers with different sagittal and transverse angulations were placed in a dry skull. With the markers in place, LHs and PRs were taken. RESULTS: A difference in the direction of crown angulation of unerupted second premolars between PR and LH occurred in 19.5% of patients. The reason for the angulation differences is a buccolingual orientation of the tooth, which appears as a mesiodistal angulation on the PR. CONCLUSION: The null hypothesis was rejected since in one-fifth of the patients premolar projection differs between the panoramic radiograph and the lateral headfilm.

Expression of proliferating cell nuclear antigen in pulp cells of extracted immature teeth preserved in two different storage media.

A specially composed medium for storing avulsed teeth has been developed. In experimental and clinical studies it could be shown that PDL cells could be kept viable during storage in the medium for up to 53 h. In the present study the medium was tested on pulp cells. A total of 40 immature unerupted third molars with open apices were removed surgically and the teeth were stored in a special cell culture medium (SCCM) or in Hank's balanced salt solution (HBSS) at room temperature for 6, 12, 18 or 24 h. Five teeth were assigned to each group. A total of seven consecutive pulp cross-sections per tooth were examined, resulting in a total of 280 specimens. Viable cells were marked using proliferating cell nuclear antigen (PCNA). The pulp was divided in three regions: apical region (0-0.5 mm), middle region (>0.5-1.5 mm) and coronal region (>1.5 mm). The labelling index (LI) was calculated for the whole cut (regions 1, 2 and 3) and for each region separately. The statistical evaluation was made using the One-way anova and Mann-Whitney Test. Pulp cells of all teeth expressed PCNA. About 110 of 140 specimens in the SCCM and 101 of 140 specimens in the HBSS group showed PCNA-positive cells. The highest LI was observed within the apical region and decreased with increased distance from the medium. No marked cells were observed at a distance of more than 1.5 mm. The LI for both media showed a significant increase with storage intervals (P < 0.05). The pulp cells of teeth stored in SCCM showed a LI nearly twice as high compared to pulp cells of teeth stored in HBSS for the apical and middle region (time interval 6, 18 and 24 h: P < 0.05). The LI for the apical region was found to be 8.43% for the SCCM and 4.50% for the HBSS after 24 h. For the middle region the LI was found to be 2.02% for the SCCM and 0.81% for the HBSS after 24 h. Within the parameters of this study, it appears that the SCCM is able to maintain pulp cell viability better than HBSS. The use of special cell culture media in case of tooth avulsion may be beneficial.

Dental injuries in inline skating - level of information and prevention.

Inline skating belongs like ice hockey, rugby, and boxing to sporting activities with high-risk of suffering tooth accidents. Because of high velocity and loss of balance, especially on uneven ground, the injury potential in inline skating is higher. The objective of this work was to conduct a comparative study between Switzerland and Germany. The questions focussed on the frequency of tooth accidents, their prevention by mouthguard and the level of information about emergency measures after dental trauma and the resulting consequences for athletes. Using a standardized questionnaire totally 612 individuals, 324 men and 288 women, in two countries belonging to three different divisions (fun, fitness and speed) were surveyed. Fifty-six (9.2%) of these 612 interviewees have already experienced a tooth injury while inline skating. More than half of all interviewed players (68.3%) were aware of the possibility of replanting avulsed teeth. Only 32.4% were familiar with the tooth rescue kit. Just 65.4% knew mouthguard and only 1.9% of those athletes (n = 12) wore a mouthguard while inline skating. The results show that the area of inline skating requires more information about preventing dental trauma through sports associations and dentists.

Interrelation between endodontic status, pathologic cemental granules and periodontal ligament adhering to the root of extracted teeth.

OBJECTIVES: To evaluate if the endodontic status has influence on the adherence of periodontal ligament (PDL) to extracted teeth and if the presence of "pathologic granules" is correlated to the endodontic status and/or the amount of adhering PDL. STUDY DESIGN: Extracted teeth with different endodontic status and exhibiting no marginal periodontitis were histologically examined. RESULTS: Observation of pathologic granules was related to a nonvital endodontium and to acute peroperative inflammation. Pathologic granules and denudation of the extracted roots were significantly related. Acute peroperative inflammation and low extraction forces were related to denudation of the roots. Such relation was not found for endodontic status, tooth type, root-form, and age of patients. CONCLUSION: The existence of pathologic granules in unexposed cementum is strictly related to teeth with a nonvital endodontium. There is no effect of the endodontic status on the adherence of PDL when an acute inflammation is absent.

Treatment of replacement resorption by intentional replantation, resection of the ankylosed sites, and Emdogain--results of a 6-year survey.

The present clinical study investigated the outcome of intentional replantation using resection of the ankylosed sites of the root, extraoral endodontic treatment using titanium posts and Emdogain for periodontal healing following trauma-related ankylosis. During an evaluation period of 6 years, 16 ankylosed teeth affected by replacement resorption were treated as described. Evaluation parameters before treatment and during the follow-up period included Periotest scores, percussion sound and periapical radiographs. All findings were compared to those of the adjacent teeth. In a second accident, one tooth was lost after 7 months and was excluded as a dropout. Ankylosis did not recur in seven replanted teeth, which were observed for an average of 52.3 months (range: 24-68 months). Ankylosis recurred in eight teeth after an average period of 12 months (range: 4-26 months). An infraocclusion, normal or only slightly reduced Periotest scores and normal percussion sound were preoperatively found in six of seven successfully replanted teeth, which corresponded to a relatively small area of ankylosis. The majority of the teeth showing recurrent ankylosis preoperatively presented with normal position, negative Periotest scores and a high percussion sound which corresponded to an extended area of ankylosis. Statistically significant relationship between preoperative findings and the treatment outcome (P = 0.031) have become apparent. The results indicate that the treatment of minor areas of ankylosis by intentional replantation, resection of the ankylosed sites and Emdogain appeared to prevent or delay the recurrence of ankylosis in 7 of 15 teeth.

Dental squash injuries - a survey among players and coaches in Switzerland, Germany and France.

Squash belongs to sporting activities with medium risk of causing dental trauma. Because of high velocity, close body contact and the use of rackets the injury potential in squash has increased. The aim of this work was to conduct a comparative study between Switzerland, Germany and France on a number of issues: the frequency of dental and facial injuries in squash, athletes' habits of wearing mouthguards, as well as the general level of information about emergency measures after a dental trauma and the resulting consequences. Using a standardized questionnaire a total of 653 individuals, 600 squash players and their 53 coaches, were interviewed. In each of the three countries 200 players belonging to four different divisions (juniors, amateurs, semi-professionals and professionals) were surveyed. Of these 653 interviewees 133 (20.4%) have already observed a dental injury; 27 (4.5%) have experienced a dental trauma themselves. Less than half of all interviewed players and coaches (47.6%) were aware of the possibility of replanting avulsed teeth. Just 5.1% were familiar with the tooth rescue kit. Only one individual wore a mouthguard. The results show that the area of squash requires more information about prevention through sports associations, coaches and dentists.

Level of information concerning dental injuries and their prevention in Swiss basketball--a survey among players and coaches.

Basketball carries a medium risk of dental injuries. Swiss data are not available in this respect. Using a standardized questionnaire 302 basketball players from 29 Swiss teams and their 29 coaches were interviewed. The questions focused on the frequency of dental accidents, their prevention and subsequent procedure. The participating 302 players came from three divisions: semi-professional players of National League A and B (102), amateurs of Regional League 2 and 3 (100) and young people of up to the age of 18 (100). The data were evaluated in relation to division, sex and team function. Of the 331 interviewed persons 102 had already seen a dental trauma in basketball and 55 had already had a dental trauma. Only four of the interviewed persons wore mouthguards. The awareness of the procedure following a dental trauma was unsatisfactory. The results of the survey show that significantly more information and education is required in Swiss basketball not only through sports associations but also through coaches and dentists.

Results after replantation of avulsed permanent teeth. I. Endodontic considerations.

Following avulsion and replantation, teeth are at risk for infection and infection related resorption (IRR). Severe discolorations of tooth crowns and cervical root fractures are common. This study presents data on endodontic related complications of avulsed teeth replanted following an extraoral endodontic treatment. Periodontal aspects will be discussed in the second part of the present publication. Twenty-eight permanent teeth in 24 patients aged seven to 17 years were replanted after avulsion. All teeth could be evaluated. In all teeth extraoral endodontic treatment by retrograde insertion of ceramic or titanium posts was performed. Mean observation period was 31.2 months (median: 24.1 months). Nine teeth healed with a functional periodontal ligament (PDL) (functional healing, FH), 19 teeth exhibited replacement resorption (RR), which was succeeded by IRR in three teeth after observation periods of more than 14 months. Diagnosis was set to tunneling resorption (one case) and to cervical resorption preceded by complete RR (two cases). No early IRR was observed. All six teeth rescued in physiologic conditions (cell culture medium of tooth rescue box) exhibited FH. Discolorations of tooth crowns or other complications (cervical root fractures, fractures of posts) were not observed. No differences in the healing results of immature and mature teeth were observed which is in contrast to previous studies. This finding is explained with the different endodontic treatment protocols. Extraoral endodontic treatment by retrograde insertion of posts prevents early IRR and minimizes the overall incidence of IRR. The method does not negatively influence periodontal healing. As there are further advantages (no discoloration, no root fractures, patient not involved, less radiographs, less time consumption, less costs) the method is recommended in isolated teeth before replantation. Especially immature teeth profit from the prevention of complications.

Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy.

The status of the periodontal ligament (PDL) and of the pulp are decisive for the healing of avulsed and replanted teeth. A tooth rescue box was developed and distributed to offer optimal storage conditions for avulsed teeth. The therapy comprised extraoral endodontic treatment and applications of medicaments to enhance periodontal healing. In this long-term clinical study the healing results following avulsion and replantation were investigated. Twenty-eight permanent teeth in 24 patients were evaluated. The extraoral storage media and periods varied considerably. Soon after avulsion six teeth were stored in a cell culture medium (tooth rescue box Dentosafe) for 1-53 h; the PDL was defined as not compromised. Sixteen teeth were stored in a non-physiologic situation temporarily, the PDL was considered as compromised. Six teeth were stored in non-physiologic conditions for longer periods; the condition of the PDL was defined as hopeless. On 14 teeth antiresorptive-regenerative therapy (ART) with the local application of glucocorticoids and enamel matrix derivative and the systemic administration of doxycyclin was used. In all teeth extraoral endodontic treatment by retrograde insertion of posts was performed. The mean observation period was 31.2 months (+/-24.1; 5.1-100.2; median: 23.8). All six teeth rescued physiologically healed with a functional PDL (functional healing, FH) irrespective of the storage period. Of eight teeth with a compromised PDL on which ART was used, three teeth healed with a functional PDL. All other teeth showed replacement resorption, in three teeth additionally infection-related resorption was recorded. The predominant influence on the healing results was the immediate physiologic rescue of avulsed teeth (chi-square, P = 0.0001). The use of ART seemed to support FH (chi-square, P = 0.0547) in teeth with a compromised PDL. No other factors (maturity of roots, crown fractures, gender, age, antibiotics) were related to healing. In a linear regression analysis physiologic storage (P = 0.0013) and ART (P = 0.0421) were related to FH. For a good prognosis avulsed teeth should be stored immediately in a cell-compatible medium. Therefore the tooth rescue box should be distributed at places with higher risks of accidents, in families with children and in emergency facilities. The use of ART might have potential for enhancing the prognosis of teeth with a PDL that is compromised but not in a hopeless condition. Extraoral endodontic treatment reduces infection-related complications; this item was discussed in the first part of the publication.