Quality Resource Guide l Traumatic Injuries and Dislocation of Teeth 2nd Edition 3 www.metdental.com different angulations or a cone-beam computed tomography image (CBCT) should be obtained. c) Treatment: Although no treatment at the time of injury is indicated, baseline pulp sensibility testing (cold and electric pulp tests) should be performed and recorded for comparison at follow- up appointments. If the tooth is excessively mobile or sensitive to biting, a flexible splint may be used for two weeks to improve the healing of the pulp and/or the periodontal ligament. 6 A flexible splint allows functional movement of the affected tooth in contrast to a rigid splint where the tooth is immobilized. 7 An ideal splint should be easily applied and removed without additional trauma to the teeth and surrounding soft tissues, stabilize the injured tooth/teeth in its correct position, and allow physiologic tooth mobility and periodontal ligament reattachment. 7 The most common types of splints are made of composite and stainless-steel wire (diameter 0.3-0.4mm), composite and fishing line, orthodontic wire (NiTi light 0.014) and bracket, and polyethylene or Kevlar fiber mesh. Materials such as Fiber-Splint (Polydentia SA Mezzovico-Vira, Switzerland), Ribbond™ (Ribbond Inc., Seattle, USA) or EverStick (Stick Tech Ltd, Turku, Finland) are commercially available. 7 d) Follow-up Examination: Clinical follow-up including periapical radiography, oral examination and pulpal sensibility testing should be performed to monitor for signs of pulp necrosis or apical periodontitis. Neither pulp canal obliteration nor negative response to testing alone should be considered an indication for endodontic treatment. Root canal therapy should only be considered if additional signs or symptoms indicate pulp necrosis. 6 Transient pulpal damage or nerve damage without damage to the pulp vasculature may result in false-negative responses to pulp sensibility tests. Normal responses may or may not return with time. In subluxation cases, follow- up appointments are indicated at two weeks, twelve weeks, six months, and one year after the initial injury to monitor for signs of pulp necrosis, apical periodontitis and external inflammatory root resorption. If external inflammatory root resorption develops, endodontic therapy should be immediately initiated using a multi-step approach with placement of calcium hydroxide [Ca(OH) 2 ] as an intracanal medicament. 6 Extrusive Luxation Extrusive luxation is a traumatic dental injury characterized by partial displacement of the tooth vertically from its socket. 10,11 a) Clinical Examination: Clinically, a luxated tooth appears elongated in an incisal/axial direction with bleeding around the gingival sulcus. The crown of the tooth is usually displaced palatally. The tooth may present with increased mobility and will not usually respond to pulp sensibility tests unless the displacement is minor. Due to the outward displacement of the tooth, tenderness to percussion and palpation, and pain during mastication are frequent findings. 6 b) Radiographic Examination: According to the IADT guidelines, radiographs recommended to diagnose extrusive luxation include one parallel periapical radiograph, two additional periapical radiographs taken at different vertical and/or horizontal angulations and an occlusal radiograph or a CBCT scan, if available. 6 The extruded tooth will radiographically show a widened periodontal ligament space apically and laterally. As noted on the clinical exam, the tooth will appear longer than the contralateral tooth and will not be seated in its socket. c) Treatment: Primary teeth - if extrusion is minor (< 3mm), gentle repositioning is indicated. If there is severe extrusive injury (> 3mm), tooth extraction may be indicated. 12 Permanent teeth - extrusive luxation injuries require immediate treatment to improve the survival chances for the tooth and supporting tissues. After administering local anesthesia and rinsing the area with saline, the tooth should be gently repositioned back into its original location. If a gingival laceration is present, the lacerated area should be sutured. Following repositioning, Table 2 - Treatment guidelines for extrusive luxation injuries Immature (open apex) Mature (closed apex) Repositioning 1. Administer local anesthesia. Reposition the tooth by gently pushing it back into its socket. 2. Stabilize the tooth with a passive and flexible splint for two (2) weeks. If a fracture of the marginal bone is noted, splint for an additional four (4) weeks. 3. Suturing may be indicated if a gingival laceration is present. Take a radiograph to confirm correct repositioning and reduction. Advise patient to have soft food for one (1) week and maintain good oral hygiene. Endodontic Considerations In teeth with open apices, monitor closely for pulp vitality. Pulp canal obliteration is a common finding. If the pulp becomes necrotic, appropriate endodontic therapy for immature teeth (apexification or pulp revascularization) should be initiated as soon as the condition of the tooth permits. If pulp necrosis is diagnosed, root canal treatment should be initiated to eliminate the infection. Placement of an intracanal medicament or corticosteroid/antibiotic initially followed by Ca(OH) 2 is recommended.