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## Complete Summary

#### GUIDELINE TITLE

Clinical guideline on management of acute dental trauma.

#### 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.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute traumatic dental injuries including:

-   Infraction

-   Crown fracture (uncomplicated or complicated)

-   Crown/root fracture

-   Root fracture

-   Concussion

-   Subluxation

-   Lateral luxation

-   Intrusion

-   Extrusion

-   Avulsion

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Dentistry\
Emergency Medicine\
Pediatrics

#### 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

### METHODOLOGY

#### 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.

### RECOMMENDATIONS

#### 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

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12105)

#### 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.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### 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

#### 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

#### 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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### 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.

#### DATE RELEASED

1991 (revised 2007 May)

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatric Dentistry - Professional Association

#### 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](http://www.aapd.org/media/policies.asp).

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](http://www.aapd.org/media/Policies_Guidelines/Intro.pdf).

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

-   [Dental growth and development
    chart](http://www.aapd.org/media/Policies_Guidelines/RS_DentGrowthandDev.pdf)

Additionally, a sample implementation tool for recording assessment of
acute traumatic injuries is included in Appendix I in the [original
guideline
document](http://www.aapd.org/media/Policies_Guidelines/G_Trauma.pdf).

#### 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.

### DISCLAIMER

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Date Modified: 11/3/2008