Traumatic dental injuries in adolescence are related frequently to risk taking behaviors that result from motor vehicle accidents, altercations with peers, or participation in recreational activities and organized sports. One overarching principle in the successful clinical management of traumatic dental injuries is to minimize the time between the injury and the initiation of dental intervention.  Not only does the time factor influence the prognosis for the injury, it is also a deterrent to future litigation based on claims of abandonment for a patient of record.
 

Successful treatment for traumatic dental injuries in the young permanent dentition also depends on the information gained through various diagnostic procedures. A determination of the nature of the accident will provide information not only on the time since the accident occurred, but also information from medico-legal and insurance perspectives. Subjective symptoms reported by the patient as to type of sensitivity or pain may be beneficial in determining the status of pulp vitality. In addition to visual clinical examination, radiographs are indicated to determine the extent of any fractures of the crown or root, the degree of displacement for luxation injuries and any associated alveolar bone involvement. It also is essential to determine the status of root end closure since the treatment options often depend on the degree of maturity of the root apex. Electrical pulp testing is frequently not definitive immediately following a traumatic dental injury and percussion testing may be ill-advised as it may further aggravate the traumatic insult to the tooth.
 

Following appropriate diagnostic procedures, the treatment plan for young permanent teeth can be established with the following goals in mind: to maintain the tooth in the dental arch; to maintain pulp vitality; to prevent root resorption; and to restore form, function, and esthetics. For the purposes of this resource guide, the management of traumatic dental injuries will be categorized as crown fractures, root fractures, and luxation injuries including avulsion.
 

Crown Fractures

Fractures to the crowns of young permanent teeth can be as mild as a chipped enamel incisal edge that may go unnoticed by the adolescent. In such instances the chipped tooth is often discovered during a routine periodic examination. In other instances of enamel-only fractures, the rough edge may irritate the tongue and smoothening and contouring may be indicated. For more extensive enamel-only fractures an acid-etched composite resin restoration may be applied to restore form, function and esthetics.
 

Crown fractures to vital teeth that extend into the dentin are sensitive to touch and temperature changes. In these instances the exposed dentin should be protected with a calcium hydroxide paste prior to bonding the acid-etched composite resin restoration to the enamel (Figure 7A and 7B). Another option is the placement of a composite resin that is directly bonded to the dentin. In those instances in which the fractured portion of the crown has been recovered and is of adequate size, the crown fragment can be reattached to the remaining portion of the tooth using a dentinal bonding agent.

Crown fractures that extend through the enamel and dentin into the pulp are more complicated from diagnostic and treatment perspectives. In addition to the diagnostic procedures listed above, treatment planning decisions for enamel-dentin-pulp fractures also should be based on pulp vitality status and the degree of root end closure.
 

In those instances where the pulp is vital and the apex is closed, the placement of calcium hydroxide followed by an acid-etched composite resin restoration remains a good option. Dentin bridge formation beneath the calcium hydroxide dressing can be anticipated as well as the maintenance of pulp vitality. Another option is the use of mineral trioxide aggregate (MTA) as the dressing on the exposed pulp, followed by an acid-etch composite resin restoration. MTA results in the formation of a denser dentinal bridge than calcium hydroxide; however, the costs associated with the use of MTA far exceed that of calcium hydroxide. Using a dentin bonding agent directly over a vital pulp exposure is not supported by the scientific literature.
 

For situations where the fracture extends into a vital pulp with an open apex, the treatment goals are to preserve pulp vitality, establish a dentinal bridge over the exposure and stimulate physiologic root end closure. The procedure to accomplish these goals is known as apexogenesis and is of particular importance in the young adolescent dentition. This procedure includes the removal of a portion of the coronal vital pulp tissue. In the more traditional technique, the entire coronal pulp tissue is amputated leaving the remaining vital radicular pulp in place. In the more conservative and equally effective Cvek technique, only a few millimeters of the superficial vital pulp tissues are amputated at the exposure site using a round diamond bur with high speed cutting and water spray. Hemorrhage control is followed by the choice of either calcium hydroxide paste or MTA as the dressing over the vital pulp. The procedure is completed by the appropriate restoration to restore form and function to the fractured crown. Dental bonding agents used directly over an exposed vital pulp should be avoided. Following dentinal bridge formation and root end closure in asymptomatic teeth, continued follow-up observation is recommended. If the tooth remains asymptomatic, then no further treatment is indicated. Endodontic intervention may become necessary if internal root resorption or periapical pathology become evident radiographically.
 

Fractures into a non-vital pulp with an open apex require a technique known as apexification. Since the pulp already is non-vital, an attempt to induce root end closure is desirable prior to initiating traditional root canal therapy. This technique involves entering the canal for mechanical instrumentation and irrigation with sodium hypochlorite. After drying the canal, a calcium hydroxide- terile water mixture is delivered into the canal. This material remains in place to induce a calcific root end closure. Radiographic observation is crucial as the dressing may need to be changed periodically or if there are any radiographic signs of internal root resorption. Following the completion of the root apex, traditional root canal techniques can be performed and an appropriate restoration placed.
 

For a fractured crown with a non-vital pulp and closed apex, traditional root canal therapy is indicated.

Root Fractures

Root fractures may occur in the apical, middle or cervical one-third of the tooth. Root fractures in the apical one-third have the best prognosis for healing as they are in an area that is stabilized by the alveolar bone, are usually not displaced, and are distant from bacterial contamination seeping through the gingival sulcus. Often apical one-third root fractures heal uneventfully. Periodic clinical and radiographic observations are recommended.
 

Middle one-third root fractures frequently are accompanied by displacement of the coronal segment of the fracture. In these instances, the distance between the stable root portion and the displaced coronal portion must be reduced with sufficient finger pressure to realign and approximate the two segments. The tooth should be stabilized with a semi-rigid, passive wire splint held in place with a small amount of composite resin material covering the wire over each tooth that is splinted. Generally, the tooth in question and one tooth on either side of the root-fractured tooth are sufficient to secure the splint. The splint should remain in place for 6 to 8 weeks and the tooth should be evaluated radiographically over this time frame for any adverse developments. In addition, it is essential for the adolescent to brush the area meticulously to diminish the ingress of bacterial contamination through the gingival sulcus. Rinses with 0.2% chlorhexidine gluconate are beneficial.
 

Fractures in the cervical one-third of the root are more problematic. They may require endodontic treatment, orthodontic extrusion, or periodontal crown lengthening for adequate restoration. Often the treatment of choice is extraction with subsequent replacement of the missing tooth in an adolescent patient. As the root apices in young permanent teeth have yet to mature, permanent replacements should be delayed until tooth development and physical growth have been completed.
 

Possible temporary replacements may include a “flipper” partial denture or a prosthetic tooth added to an orthodontic or retaining-type appliance. A more permanent replacement such a single tooth implant should be delayed until the completion of the growth potential in adolescent patients. Of particular note, consideration must be given to the completion of passive eruption of the permanent teeth prior to placement of the implant. Even though implant placement in adolescent women over 15 years of age and adolescent men over 18 years of age has been suggested, it may be more prudent to delay placement until at least 18 to 19 years based on the completion of passive eruption.
 

For additional information related to crown and root fractures in the permanent dentition, the reader is referred to the MetLife Quality Resource Guide entitled, Traumatic Injuries and Tooth Fractures, 2nd Edition.
 

Displaced Teeth

The vectors of traumatic force determine the direction and severity of tooth displacement in young permanent teeth. A force that does not cause clinically observable movement of the permanent tooth within the alveolus is referred to as subluxation. Other force vectors may result in lateral, intrusive, or extrusive luxations. The most severe form of displacement is exarticulation or avulsion of the tooth completely out of the socket. The time interval between the injury and the initiation of treatment as well as the extent of damage to the periodontal ligament (PDL) are crucial to a successful outcome.
 

The first principle in the management of a displaced tooth that remains in the socket is to reposition the tooth into its normal position. This is followed by the placement of a passive semi-rigid, composite bonded wire splint for 7 to 10 days. Meticulous home care is essential and the use of 0.2% chlorhexidine gluconate is beneficial. Particular note should be taken for any radiographic signs of external root resorption. If resorption develops or if the tooth becomes symptomatic, root canal therapy is recommended.
 

For avulsed (exarticulated) teeth the best recommendation is to reinsert the tooth back into the socket as soon as possible. The tooth should be handled carefully by the crown only to avoid additional damage to the PDL tissues that remain on the root surface. If debris is observed on the root or PDL, it should be removed gently with a stream of liquid such as water, milk or Hank’s balanced saline solution. The root or PDL must not be scraped in any manner. Following reinsertion of the tooth back into the socket, the patient should be asked to bite down gently on gauze and transported to the dental office for splint placement.

In those instances where individuals at the accident site are uncomfortable with reinserting the avulsed tooth back into the socket, the tooth should be immersed in a liquid for transport with the patient to the dental office with all due haste. Appropriate liquids include Hank’s balanced saline solution, milk (skim milk is preferable), or if neither of these is available water is preferable to transporting the tooth dry. Hank’s balanced saline solution is available commercially as tooth preservation kits.

In situations involving blood exposure to the elements, tetanus immunization status should be questioned and appropriate referral to the patient’s physician may be indicated. For avulsed teeth prescribing a systemic antibiotic may be indicated. For all traumatic injuries the dentist should consider performing a rapid neurological assessment for signs of mild traumatic brain injury (concussion).

For additional information related to displaced permanent teeth, the reader is referred to the MetLife Quality Resource guide entitled, Traumatic Dislocation of Teeth, 2nd Edition.