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Following a severe traumatic incident to permanent immature teeth, the growth of calcified tissue in the pulp space may occasionally occur. This calcified tissue may be diffuse or in intimate contact with the dentine. It has been suggested that a wide open apex, severe damage to the root sheath, and the absence of infection are only some of the predisposing factors leading to this metaplasia of pulp tissue into bone-like tissue. Five cases are described.

The prevalence and yearly incidence of traumatic tooth injury between 1 and 16 years of age have been studied in a cohort of 16-year-olds, born in 1975, and residing in the County of Västerbotten. The study material comprised 3007 dental records from the Public Dental Health Service. Of these, 1040 contained information on dental injuries. Out of 1000 injured primary teeth, 32% were lost, either avulsed at the time of the accident or extracted due to complications. A majority (92%) of the extractions was performed at the first or second follow-up. A total of 690 tooth injury episodes had occurred in the permanent dentition, involving 981 teeth. In 10% of the teeth more than one diagnosis was recorded for the same tooth. 416 restorations were performed due to crown fractures, the majority at the emergency visit. 44% of the patients had to come back one or more times to revise the composite restoration. Complicated fractures or serious luxation injuries constituted only 5% of the total number of injuries in the permanent dentition. 77 (8%) of the traumatised teeth were treated endodontically. Two percent of the teeth with uncomplicated crown fractures required endodontic treatment due to pulp necrosis, while 28% of teeth with a combination of crown fractures and luxation injury were endodontically treated. Out of 6 avulsed incisors, 4 survived after endodontic treatment. A total of 7 incisors were lost as a consequence of the injuries. A specialist treated 4% of the patients.

The aims of the study were to determine the main aetiological factors involved in injuries to anterior teeth and to identify factors influencing the attendance for emergency care. This information is essential, first, for planning dental health education programmes aimed at reducing the incidence of dental trauma and, second, to devise strategies for its effective treatment. Of 2022 schoolchildren examined for evidence of dental trauma, 696 (34%) had experienced injury and were interviewed regarding this injury. Of these, 403 knew about their damaged front tooth, but only 330 recollected the incident causing the injury. Over one third of accidents occurred at home and a further 25% at school. The most common cause of injury was falling onto a hard surface or object (34%) with accidents involving bicycles or other sporting activities accounting for a further 30%. Factors found to be significantly related to attendance for emergency care were experience of pain, unattractive appearance of the injured tooth and social classification, with children from higher income, more affluent areas being more likely to seek treatment. The majority of dental injuries were the result of genuine accidents which were almost impossible to prevent. This study highlighted the need for attention to be brought to parents, children, lay people and health care professionals that all dental injuries should be examined by a dentist, not just those injuries resulting in pain or poor aesthetics.

The objective of this in vitro study was to investigate the impact strength of anterior teeth that have been fractured and restored by bonding with a dentin-bonding agent and a composite resin. Twenty sheep central incisors were divided into two groups, 10 in each. One group (intact teeth) served as the control and the teeth in the other group were fractured and then bonded with a bonding agent and a low-viscous composite resin. The specimens were tested in a modified impact-testing machine (pendulum type). The mean impact strength of the intact teeth was 30.6 +/- 2.16 KJ/m2 and of the bonded teeth was 30.2 +/- 1.86 KJ/m2. Statistics revealed that the two means were not significantly different. The results related well with the fracture strength obtained by loading intact and bonded teeth at constant but low speed until fracture. It was concluded that bonding fragments to the remaining tooth structure may restore the tooth to its original strength, measured at modest velocities of the applied force. In other words, reattaching the original coronal fragment of traumatised fractured anterior teeth restored with One-Step dentin bonding system and AEliteflo composite resin would withstand a second trauma to the same extent as intact teeth.

Between 1979 and 1997, 58 avulsed primary teeth were treated at the Pedodontic Clinic of Niigata University Dental Hospital. Among these, we replanted six avulsed incisors of four patients and treated two teeth of two patients replanted at other dental clinics. Referring to the clinical records, oral photographs and radiographs, we examined the injury age, cause of injury, condition of tooth storage, length of time until replantation, and also the prognosis after replantation. Three teeth of two cases remained until eruption of their permanent successors, and one tooth of one case remained under observation without extraction. Although the other four teeth of three cases resulted in extraction, no secondary infection was detected due to replantation. The following reasons were suspected for the poor prognosis of the four teeth. One avulsed tooth was not fixed immediately after replantation. One replanted tooth might not have been compatible with the alveolar socket. In the other two teeth, the periodontal vital tissues might have been removed before replantation. It is generally suggested that replantation of primary teeth is not a good option. However, from the present results, it was considered that replantation can be an effectual method when the condition of the avulsed primary tooth is suitable.

This case report describes the treatment of an 18-year-old male who lost two central maxillary incisors due to dental trauma. Because of a deep overbite and serious occlusal instability, the lost teeth 11 and 21 could not be replaced by a conventional fixed prosthesis. The vertical dimension of occlusion was increased using a Hawley-type appliance over a period of 1 year. When sufficient intermaxillary space was gained the alveolar ridge was augmented with a mandibular symphysis graft. Nine months later two one-stage non-submerged implants (ITI, Straumann, Waldenburg, Switzerland) were inserted. After further soft tissue adaptation to two temporary acrylic crowns, porcelain veneers were placed on the two implants and the lateral incisors.

Increased overjet and inadequate lip coverage of the maxillary incisors are considered significant risk factors in many clinical studies. The purpose of the present study was to examine this issue of dental injury by actual cephalometric measurements in orthodontic patients. Pretreatment cephalograms (taken with lips in repose) of consecutive patients were used. The patients were allotted to two groups Group T (trauma): 56 patients who had injured their maxillary incisors prior to their orthodontic treatment, mean age at the start of treatment 11.9 years (SD = 1.5); and Group C (control): 98 patients with intact maxillary incisors, mean age at the start of treatment 11.6 years (SD = 1.3). Twelve cephalometric landmarks on the soft and hard tissue profile were identified and digitized and the relevant dental, skeletal and soft tissue measurements recorded. The variables in Groups T and C were compared and their predictive values for possible occurrence of trauma were tested by logistic regression analysis. No statistically significant differences between boys and girls were found. Overjet or maxillary incisor exposure or interlabial gap, each as a single variable, could differentiate between the two groups. Logistic regression analysis indicated that only a small percentage (28.7%) of the dependent variable variation (trauma vs control) can be explained by interlabial gap, gender, upper incisor long axis to facial plane (degree), upper incisor long axis to interlabial gap and overjet.

Unlabelled: A computer-assisted learning program with a tutorial, self-assessment exercises and an expert system has been developed. Sixty-seven general dental practitioners were requested to evaluate the program. The results from those practitioners who returned the questionnaire showed that 57% found the program generally easy to use with the appropriate level of difficulty of tasks and content of supporting information, which it was felt improved their knowledge of the management of fractured incisors., Conclusion: It is worthwhile to develop such programs for the education of general dental practitioners. All users of this program felt that it was better than video, audio tapes, journals or books on the subject.

Laser Doppler flowmetry is a non-invasive electrooptical technique which allows the semi-quantitative recording of pulpal blood flow. This study aimed to determine the reliability (measured as the sensitivity and specificity) of laser Doppler flowmetry as a method of assessing the vitality of traumatised anterior teeth, and to compare it with standard pulpal diagnostic tests. Recordings of pulpal blood flow were taken from 67 non-vital anterior teeth (55 patients), where the pulpal status was confirmed by pulpectomy. For comparison, recordings were also taken from 84 vital anterior teeth (84 patients). Analysis of the recordings allowed diagnostic criteria to be developed which gave the technique a sensitivity and specificity of 1.0 for this sample. None of the other standard pulpal diagnostic methods tested was as reliable. This was usually due to low sensitivities, which ranged between 0.92 for sensibility testing with ethyl chloride down to 0.36 for periapical radiolucency and 0.16 for a history of pain. Laser Doppler flowmetry was found to be a reliable method of assessing the pulpal status of traumatised anterior teeth, although it is technique-sensitive and time-consuming to use.

Tooth aspiration is one of the rare sequelae of dental trauma. When this does occur, the right bronchus is usually involved in adults due to the anatomical configuration. In this unusual case, two teeth were aspirated with one entering each lung. While the outcome from cases of aspiration of foreign bodies is usually favourable, this case serves to illustrate one of the possible unfavourable consequences.

Patients who present with discolored and/or symptomatic anterior teeth for which there are no obvious etiologic factors should be carefully questioned regarding their past surgical history. If the patient denies a history of trauma yet relates a recent, (2-5 years) history of undergoing general anesthesia, a differential diagnosis including trauma secondary to endotracheal intubation should be considered.

The case describes the management of an avulsed maxillary central primary incisor of a 3 1/2-year-old girl. The tooth was retained in the oral cavity for 30 min. After replantation it was splinted for 17 days. At day 11 the root canal was completely instrumented and obturated with a calcium hydroxide paste. The 1-year follow-up documented no pathologic clinical or radiographic findings. One and a half years after the trauma the tooth was extracted since a fistula and extensive external inflammatory resorption had developed. The permanent successor erupted along with its neighboring central incisor without any complications 6 months later. Conventional approaches for treating avulsed permanent teeth could also be applied to avulsed primary incisors to preserve them for a certain period without the additional risk of damaging their developing permanent successors.

Fractured anterior teeth can be restored by adhesive bonding of the fragment to the remaining tooth structure. This in vitro study describes the effect on fracture strength of fragments dried and rewetted for various periods of time prior to bonding. Seventy central incisors from sheep were fractured. The resulting incisal crown fragments were then stored in air at room temperature at ambient humidity (70 +/- 16%) for 5 s, 30 min, 1 h, 3 h, 6 h, 12 h, or 24 h. The apical parts of the fractured teeth were stored in water. After storage in air each fragment was then bonded to the matching apical tooth structure with a bonding agent and a low-viscosity composite resin. After water storage for 2 days, mean fracture strength was measured. Another group of teeth comprising 40 sheep central incisors was fractured and the fragments were stored in air at room temperature for 24 h as above. The fragments were then immersed in water for 10 min, 1 h, 1 day, or 7 days, prior to bonding and measurement as described above. Statistical analysis revealed that the fracture strength of the fragment-bonded teeth was unaffected by air storage of the fragment for up to 1 h prior to bonding, after which additional drying resulted in decreased fracture strength. Fragments dried for 24 h in air and rewetted by immersion in water for at least 1 day were fragment-bonded without loss of fracture strength.

This paper describes the case of a 31-year-old woman with advanced periodontal disease who lost a tooth due to trauma. The avulsed tooth had minimal bony support of only 4-5 mm. The patient described was under good periodontal maintenance. The tooth was kept moist, and replantation occurred within an hour of avulsion. The tooth was returned to its position, splinted, and later endodontically treated. After 2 years the tooth appears and functions normally as it did before avulsion.

This cross-sectional survey was carried out to assess epidemiological data concerning dental injuries to the permanent incisors of Syrian children. It included 1087 children aged 9 to 12 years, of both sexes, randomly selected from public and private primary schools in Damascus. The response rate was 100%. The prevalence of traumatic injuries to the permanent incisors rose from 5.2% at the age of 9 years to 11.7% at the age of 12 years (P = 0.007). The difference in prevalence between boys and girls was not statistically significant (P > 0.05). The majority (59.8%) of children who had experienced injuries to the permanent incisors reported that they were not taken to the dentist for evaluation or treatment of the damage. Among those children who had experienced traumatic injuries to the teeth 93.1% presented with untreated damage. Because some injuries were minor, such as small enamel fractures, the proportion of children who needed treatment was 63.2%. There was a tendency for children with an incisal overjet greater than 5 mm to have experienced dental injuries (P = 0.06). Children with inadequate lip coverage were more likely to have experienced dental injuries than those with adequate lip coverage (P = 0.000). The most common reported cause of injuries to the permanent incisors was violence (42.5%), followed by traffic accidents (24.1%), collisions with people or inanimate objects (16.0%) and falls (9.1%). In conclusion, traumatic dental injury may pose a serious dental public health problem.

A case of severe lateral luxation and root fracture in upper incisors is reported. Treatment involved the repositioning and fixation of the injured teeth and endodontic treatment with calcium hydroxide. The importance of long-term follow-up is emphasized.

Mineralization in the pulp is a common finding in permanent as well as primary teeth and is associated with caries, aging, traumatic injuries and systemic conditions. This article describes an unusual pattern of pulpal calcification. A tube-like calcified structure formed in the dental pulp of primary incisors following mild traumatic injuries. It was studied by clinical, radiographic and histologic evaluation and by scanning electron microscopy. The tube-like structure was found to extend along the entire length of the pulp canal. Generally it was separated from the root dentin by normal pulp tissue, but was connected to the dentin in some sites. It had the histologic appearance of osteodentin with cell inclusions in a ring-like formation that was incomplete in places. The scanning electron microscope study showed rough inner and outer surfaces of a tube-like structure with openings that seemed to be dentinal tubules.

This in vitro study investigated the fracture strengths of fractured incisors after reattachment to the remaining tooth structure, using either Gluma dentin-bonding agent together with 1 of 13 different experimental resins or 1 of the following dentin-bonding agents: Gluma+ (experimental modification of Gluma), Panavia21, ScotchBond1 (SingleBond), All-Bond2, Dentastic, SuperBond, Prime&Bond 2.1. No significant differences were found in the experiments with various experimental resins. The fracture strength of teeth rebonded with Gluma, All-Bond2, Dentastic, SuperBond or Prime&Bond 2.1 showed mean fracture strengths in the range of 8.7-11.2 MPa, which were significantly different in all cases from that of intact teeth (16.3 MPa). Teeth bonded with Gluma+, Panavia21 or ScotchBond1 (SingleBond) showed mean fracture strengths of 15.5, 14.6, and 14.2 MPa, respectively. These fracture strengths were not significantly different from that of intact teeth.

Two hundred and eighty-seven children with a total of 545 traumatized primary upper incisors were followed using standardized procedures until the age of 10. Extraction was the only treatment offered when intervention was necessary. The immediate as well as the long-term consequences of trauma were studied on the basis of this material. Consequences in the primary dentition comprised: color changes (53%), pulp necrosis (25%), pulp canal obliteration (36%), gingival retraction (6%), permanent displacement after luxation (5-22%), pathological root resorption (1-10%) as well as disturbances in physiological root resorption (4%) and, lastly, premature tooth loss (46%). In a multivariate analysis of the development of pulp necross in primary teeth after trauma, the following decisive factors were found: age of the patient at the time of injury, degree of displacement of the tooth as well as the degree of loosening and presence of crown fracture. The factors found to influence development of pulp canal obliteration were: displacement of the tooth at time of injury as well as detectable physiologic root resorption at time of trauma. The presence of crown fracture seemed to decrease the risk of obliteration. The need for scientifically based treatment strategies for managing and reducting complications after trauma in the primary dentition is stressed.

Trauma to primary teeth may result in direct damage to underlying developing permanent teeth because of the close relationship that exists between the apices of the primary teeth and their permanent successors. Injuries to developing teeth have been classified into ten different categories, using a classification that is largely based on developmental alterations to the permanent teeth. However, this classification does not include other types of trauma that may occur to developing teeth, such as crown fractures. Although apparently rare, such injuries can occur by direct contact of the impacting object with a developing tooth, as illustrated by the following case report.

The purpose of this study was to identify the variables that significantly influenced the survival of incisors replanted after extended extra-alveolar duration at The Hospital for Sick Children, Toronto, Canada, between June 1988 and December 1993. Survival analysis was used to identify variables that significantly influence the retention of replanted incisor teeth. Survival was defined as the time that elapsed between the replantation of an avulsed incisor and the time it was finally lost. Information on 9 variables was collected for 38 patients (25 males; 13 females) and 52 replanted permanent maxillary incisors. The mean extra-alveolar duration for the sample was 123 min. The mean follow-up interval was 942 days (range: 364-2126 days). Incisors replanted with open apices had a significantly decreased survival compared with teeth with mature apices (P = 0.04; relative risk 4.2). There was also a significant association between increased survival and obturation of the root canal with gutta-percha and sealer (P = 0.006; relative risk 10.0). A trend towards improved survival of replanted incisors was found for children older than 11 years old at the time of replantation (P = 0.09; relative risk 2.8). These results are consistent with previous studies and may assist clinicians and parents in the decision-making process associated with the management of avulsed teeth in children.

A case is presented in which combined endodontic and orthodontic therapy was performed in traumatically injured teeth 12 months after an accident. Calcium hydroxide treatment was used to halt any possible resorption during orthodontic treatment. The teeth were repositioned in a desirable manner without any complication by orthodontic treatment. Root canal obturation was accomplished after the completion of active orthodontic treatment. Recall examination 12 months after completion of root canal treatment showed clinical and radiographic evidence of healing.

Cervical third horizontal root fractures in immature permanent teeth often present complicated and unpredictable treatment options. This case report describes the successful management of a horizontal root fracture in an open apex tooth by vital root submergence and subsequent nonsurgical root canal therapy.

We present the case of a 26-year-old man who at the age of 9 suffered severe trauma to both maxillary central incisors. The underlying malocclusion was skeletal and classified as dental Class II/1 with severe crowding. Both the maxillary central incisors and the two lower first premolars were extracted and the patient was treated with an edgewise appliance for 2 years. Acceptable occlusal relationships were achieved following orthodontic and adjunctive treatment which consisted of reshaping the maxillary lateral incisors with composite materials and grinding the canines to resemble lateral incisors. A critical evaluation of the esthetic and functional results at the age of 26 years is presented.

The aim of this study was to determine the periodontal healing of replanted dogs' teeth which, after extended extra-oral dry times, had been soaked in various media before replantation. Incisors and premolars of beagle dogs were root canal treated, extracted and bench dried. The teeth were grouped according to dry times of 30, 45 and 60 minutes. Each group of teeth was soaked in one of three media, Hank's balanced salt solution, ViaSpan (Belzer UW-CSS, Dupont Pharmaceuticals), or Conditioned Medium (supernatant of confluent culture of human gingival fibroblasts) for 30 minutes before replantation. Controls consisted of teeth extracted and replanted without drying on soaking (negative control), and bench-dried teeth replanted without soaking in the media (positive control). The dogs were killed 6 months after replantation of the teeth, which were prepared for histologic evaluation. Five microns cross-sections (every 70 microns) of the root and surrounding tissue were evaluated for healing/resorption according to Andreasen's criteria. The best healing occurred for the roots which had been immediately replanted. Healing in the positive control groups decreased with increased dry time. For the 30-minute dry time groups, soaking in media had no beneficial effect on periodontal healing compared with the controls. Soaking in ViaSpan resulted in an increased healing incidence for both the 45- and 60-minute bench-dried groups while soaking in the other media had no consistent beneficial effect. It appears from this study that an avulsed tooth that has been left dry for 30 minutes should be replanted immediately without soaking. However, teeth that have been dry for 45 or 60 minutes would benefit from soaking for 30 minutes in ViaSpan.

A case of a 9-year-old boy who presented with intruded maxillary central incisors, one of which had also sustained a middle third root fracture, is reported. The root fracture was diagnosed after orthodontic extrusion was started, which resulted in separation of the apical and coronal fragments. The hypermobile coronal fragment was stabilised by passing a K file through a palatal access cavity into the root canal of the apical fragment. Orthodontic alignment was completed and the fractured incisors were restored with the file left in situ. At a 10-year follow-up, the incisors were clinically healthy and continued to satisfy aesthetic and functional demands.

The prognosis of replanted avulsed permanent incisors depends largely on prompt and appropriate emergency management. The aim of this study was to investigate lay knowledge and attitudes in this respect. Postal questionnaires were sent to all physical education teachers, school nurses and secretaries, attendants in swimming baths and leisure centres and to 220 parents of teenage children in a defined area of North West England. The overall questionnaire response rate was 86.9%. Knowledge of methods of dealing with this problem was generally inadequate in both parents and the other groups. Although 53.6% of respondents claimed to have received first aid training only 3.1% could remember dental injuries being included. There was evidence that dental health education in this field can be effective, since the highest mean knowledge score was found in the 11.5% of respondents who recalled receiving advice from sources such as posters, magazines and newspapers. More than 80% of the respondents stated that they would not want to replant an avulsed incisor themselves, the main reason being lack of knowledge and training. It is suggested that there is a need for potentially effective dental health education in relation to this problem.

Infection of the pulp space in addition to the attachment damage of a traumatic injury to a tooth, results in serious complications and often tooth loss. Therefore, the prevention or treatment of root canal infection is a major consideration in these cases. In immature teeth, revascularization of a necrotic pulp is possible and highly desirable. Unfortunately, current sensitivity tests are poor indicators of revascularization, with the result that many pulps are removed unnecessarily. Laser Doppler flowmetry is an objective test of the presence of moving red blood cells within a tissue, which has been reported to be effective in the detection of tooth pulp vitality as well. A case is presented where an eight year old child severely luxated both maxillary central incisors. While only one of the incisors was weakly responsive to CO2 ice at 76 days after replantation, the laser Doppler flowmeter indicated that revascularization was occurring in both teeth at a much earlier time. Because of the laser Doppler readings, endodontic treatment was not initiated and the teeth developed normally.

Combined trauma involving intrusive luxation of one tooth and avulsion of another is rare. A case is presented involving the endodontic management of two traumatised maxillary central incisors, one of which was intrusively luxated and the other avulsed. Spontaneous re-eruption of the intruded tooth occurred, thereby avoiding the need to further traumatise the periodontal ligament with either orthodontic or surgical repositioning, and allowing endodontic therapy to be carried out uneventfully. Endodontic therapy of the avulsed tooth was completed and its prognosis is considered good.

In the present study, the prevalence of traumatic injuries to anterior teeth in 824, 6- to 11-year-old, schoolchildren from Rome (Italy) and the relationship between injuries and predisposing factors were evaluated. Prevalence value of the study-population was 20.26%. This value is higher than those reported in surveys performed in Italian emergency dental services, but it is similar to those of retrospective studies from other countries. The highest prevalence was found among 9-year-old boys (33.69%); the M/F ratio was 1.64. The percentage of injuries with unknown cause (21.46%) was higher than that of other studies. This may be because most of injuries were slight (64.39% of injuries were enamel fractures) and it is likely that children and their parents were not worried about them, when they happened, so that they did not seek urgent dental care-this helps to explain the prevalence values of this and other retrospective studies, which are higher than those from emergency services-and, when interviewed, they did not remember the circumstances of the traumatic event. Using the Mantel-Haenszel's Odds Ratios stratified for age and sex, injuries were related to individual predisposing factors (overjet larger than 3 mm: OR = 2.57, p = 0.0001, short upper lip: OR = 2.23, p = 0.0001 and upper medial incisor protrusion: OR = 3.95, p = n.s.), but not to children's trauma predisposing behaviour (OR = 0.92, p = n.s.). Serious injuries, however, happened to children without predisposing factors and were caused by strong impacts, suggesting that individual risk factors may not affect these type of injuries.

One of the aims in treating traumatised teeth is to maintain the vitality of the pulp or allow conditions favourable for pulp revascularisation. However, infection of the pulp and root canal system may prevent this. A number of pathways have been proposed that allow bacteria to invade the root canal system, however most of these pathways cannot account for pulp infection in teeth that did not sustain injury to the periodontal attachment. Enamel/dentine cracks have been proposed as a portal for bacterial invasion of seemingly intact teeth and the aim of this study was to determine if bacteria could invade the root canal system after a simulated traumatic episode. Twenty intact and sound upper central incisors were chosen and prepared. One tooth was selected as a sterility control and the external crown surface of the remaining 19 teeth was subjected to infection with Streptococcus gordonii in a bacterial microleakage model. Over 7 days samples of growth media from the root canal system were taken and tested for bacteria. Sixteen of the teeth did not demonstrate bacterial invasion over the time frame. These teeth were then prepared for testing in a pendulum impact device and were subjected to a blow which did not fracture the crowns or dislodge the tooth from its simulated alveolus. The teeth were then prepared and tested in the bacterial microleakage model. After impact seven of the teeth demonstrated bacterial invasion of the root canal system (P = 0.002). These teeth were then reprepared for testing in the bacterial microleakage model. The crowns of five teeth, selected at random, were coated with two layers of light cured unfilled resin, the remaining two were used as positive controls. All the teeth coated with resin did not demonstrate bacterial invasion (P = 0.00), while the positive controls demonstrated invasion. The results suggested that enamel/dentine infractions were pathways for bacterial invasion of the root canal system of traumatised teeth. The application of unfilled resin to the anatomical crown prevented infection.

Sports-related dental trauma remains a risk for children and adolescents. Although mouthguards provide protection, up to 25% of dentoalveolar injuries can occur with a mouthguard in place. This study examined the effect of mouthguard protection in an in vitro model. A total of 97 sheep mandibular segments with incisors at four developmental stages (early deciduous, ED, n = 37; middle deciduous, MD, n = 20; late deciduous, LD, n = 18; mixed dentition, PD, n = 22) was used. Customised pressure formed mouthguards (MG) provided protection from trauma produced by a servohydraulic materials testing machine to test incisors. Injuries were examined clinically, radiographically and by dissection. Mean forces required to produce dentoalveolar injury were significantly greater in test (with MG) teeth than control (no MG) teeth. Mean forces to produce injury in test teeth decreased with resorbing root lengths. Deciduous incisors differed in injury type: subluxations and horizontal root fractures predominated in test teeth; lateral luxations and horizontal root fractures in control teeth. Predominant injuries in test and control permanent incisors were enamel infractions and subluxations. The magnitude of lateral luxation measurements of individual teeth was reduced significantly by mouthguard protection in both deciduous and permanent dentitions. The mouthguard tended to increase the mobility of the teeth it encompassed and, in some instances, promoted dentoalveolar injury of adjacent teeth.

A periodontally affected tooth was prepared for a special treatment: Calcium hydroxide was introduced into the apical half of the root canal whereas its cervical part was filled with glass ionomer cement. The tooth was shortened subgingivally. After 6 weeks of epithelization over the residual root a palatal full-thickness flap was mobilized. The root was carefully extracted and chairside copy-milled from the biodegradable polylactic acid (PLA) material. The PLA-replica was implanted immediately into the socket and the flap was sutured. Aim of the treatment was to prevent the ridge collapse of the extraction area. Ridge height could be preserved during the 21 months of observation. With time the radiographic density of the cancellous bone increased in the implanted area, indicating that a PLA-replica is replaced by host's bone tissue.

Traumatic intrusion of permanent teeth is a relatively infrequent but serious type of dental injury, due to the complicated picture it involves. Various treatment approaches have been suggested, so far, regarding management of intrusive luxation. Techniques aiming to reposition the intruded tooth include observation for spontaneous reeruption, surgical as well as orthodontic repositioning. However, development of complications such as pulp necrosis, inflammatory root resorption, replacement resorption and ankylosis and loss of marginal bone support makes selection of the most favorable technique controversial. In this paper, a critical review of the existing treatment modalities is attempted and treatment approaches based on diagnostic parameters that are indicative of the severity of an intrusive injury are presented. Recommendations are made after taking into consideration experimental and clinical study findings and observations from other author's and our own clinical experience. Two cases of intrusive luxation in children are presented and management of the dental injuries as well as the complications which occurred are being discussed.

The prognosis of 56 root-fractured permanent incisors was evaluated clinically and radiographically for 2 to 31 years. Information about initial case histories, examination and treatment of root-fractured teeth were recorded retrospectively from patient cards. Most of the root fractures occurred in the 16-20 year age group (38%) followed by the 11-15 year age group (29%). Males were involved more often than females. Fifty-two percent of the patients visited the dental clinic within the first week, while 48% did so 1 month-31 years later after the injury. The leading cause of root fractured injuries was falls (46%) and mostly involved one tooth (71%). Maxillary central incisors were the most often affected teeth (95%). The most common type of root fracture was in the middle third of the root (57%) followed by apical part (34%). About 59% of untreated or splinted teeth maintained their vitality. Healing with connective tissue was observed in 19 teeth, with calcified tissue in 15 teeth and with osseous tissue in only one tooth. There was partial or complete obliteration of the pulp space in these healed cases (62.5%). The formation of pulpal hard tissue produced no additional clinical problems. Partial or total pulp necrosis were noted in 21 (37.5%) teeth. Endodontic treatment was successful in 12 cases. The remaining 9 teeth were extracted due to the loss of marginal alveolar bone and apical periodontitis.

Although there are several epidemiological studies on dental trauma internationally, there are not many studies that record, analyse and follow different kinds of dental trauma treated in a private office, and that evaluate how parameters such as type of dental trauma, as well as time lapse until treatment might influence the final outcome and the prognosis of the teeth. The sample consisted of 242 patients, 6-17 years of age, with 369 injured teeth treated within a period of 5 years. All the case were treated by the first author and were followed for at least 3 years. The treatment modalities used were based upon the clinical examination and the history of the case and included direct and indirect pulp capping, partial pulpotomy, pulpotomy, pulpectomy and splinting. The type of trauma was classified based on WHO classification partially modified. Seventy six percent of the teeth suffered only hard tissue injuries and 22% had only periodontal ligament PDL) trauma. Of the total number of teeth class I represented 3%, class II 59%, class III 20% and class IV 2%. Of the PDL injuries 14% of the teeth suffered concussion, 69% luxation and 17% exarticulation. The highest incidence of dental trauma was observed at the age of 10. Sixty eight percent of the patients sought treatment 3 days or more after the trauma had occurred delayed treatment), while only 32% within the first 3 days (immediate treatment). The main reasons for delayed treatment were neglect (50%) and unawareness 37%). Of the teeth with delayed treatment 43% became necrotic, while only 28% of the teeth that were treated on time needed pulpectomy. Luxations caused more pulp necrosis (46%) than Class I (0%) Class II (7%) or Class III (34%) type of trauma. The data from this study suggested that a most of the dental injuries on permanent teeth were class II or III type, b) a high percentage (68%) of the patients sought treatment more than 3 days after the injury (delayed treatment), c) delayed treatment caused more necrotic teeth, d) the public should be informed of the importance of immediate treatment in an effort to improve the prognosis of the pulp, e) dentists should be informed of the appropriate treatment of dental injuries since 10.3% of the cases were mistreated.

A follow-up study of crown fractured permanent incisors with incomplete root formation was carried out in a group of patients, aged 6-12 years, over a 5-year period in the Dental Clinic of the University of Verona, Italy. The number of injured patients was 55, representing 84 injured incisors. All patients were followed clinically and radiographically using a standardized follow-up protocol. The most common type of trauma was fracture of enamel and dentine without pulpal exposure (80%) and the most common type of treatment was restoration with the acid-etch composite resin technique (46%). Bonding of the crown fragment was performed in 10 instances (12%). At the 5-year-control all teeth with fracture of the enamel had no pulp complications. Four of 67 teeth (6%) with fracture of the enamel and dentine without pulpal involvement showed pulp necrosis and 1 tooth showed pulp obliteration (1.5%). Eight of 14 teeth (57%) with fractures of the enamel and dentine with pulp involvement showed pulp necrosis. Aesthetically 36 of the restored teeth were deemed satisfactory (43%). In 9 teeth the bonded fragment had to be rebonded. 14 teeth were considered unsatisfactorily restored due to wear of the composite (17%). 34 restored teeth had to be retreated because of a new trauma (40%). In one tooth a previous bonded fragment had to be rebonded. These results confirmed that crown fractures without pulp involvement in permanent incisors with incomplete root formation hav a low percentage of pulp complications, while 60% of the teeth with crown fractures with pulp involvement had pulp complications.

Re-implantation is the recommended therapeutic procedure following traumatic exarticulation of teeth though its long-term prognosis remains controversial. The purpose of the following study was to evaluate the periodontal healing of 33 reimplanted incisors lost after trauma. The sample, which included 24 upper and 9 lower incisors, was divided in two groups: 15 teeth were reimplanted within 1 hour (=Group A) and 21 teeth after 3 hours or more (=Group B). The reimplanted teeth were followed for different radiographic evaluation periods up to 5 years (mean=2-9 years). The results showed a high rate of periodontal healing in Group A (66.7%), while Group B demonstrated a high percentage (83.3%) of both inflammatory and replacement resorption. Thus, even if the whole sample was prevented from drying before reimplantation, the teeth were affected by different rates of root resorption. Among the various prognostic factors suggested by the literature, bacterial contamination during extra-alveolar storage seemed the most critical.

470 injured teeth of 370 patients who consulted the Dental Clinic of Ege University, Izmir, Turkey for examination or treatment between 1981-1993 were evaluated. Information concerning sex, age of patients at the time of injury, cause of trauma, number of injured teeth, type of tooth and type of trauma were recorded. More boys suffered traumatic injuries (64.8%) than girls (35.2%). Patients aged 11-15 years old exhibited the highest number of injuries (34.4%) followed by the 6-10 years old group (24.5%). Most injuries involved one tooth (60%) and maxillary central incisors were the most often affected teeth (66.2%). The leading cause of injury was undefined falls (45.1%). At the initial examination, cases seen after a long posttraumatic period showed more complications than those presented within a short time period. Educational programs about the importance of dental trauma, the benefits of immediate attendance and conservation of avulsed and fractured teeth would be very helpful for patients. Additionally improving the knowledge of the dental practitioner about trauma would be another important point in solving the problem.

A representative sample of 2020 schoolchildren, aged 6 to 15 years, was randomly selected from 85 state and private schools in Rennes and distributed in 10 groups, according to their age. Type and prevalence of dental injuries were determined in each group, using Ellis & Davey's classification, giving rise to a subset of 345 subjects. Simple enamel fracture was the predominant injury (59.4%), occurring most often on maxillary central incisors. Most time (77.1%), the trauma affected only one tooth. Mean prevalence of dental injuries was 13.6% from 2020 subjects. Boys showed a higher prevalence than girls (respectively 17% and 10.2%), but this difference was only significant for age-groups 12 and 13 (p < 0.001) and for the whole group of 6-15 (p < 0.001).

This in vitro study investigated the shear bond strengths of sectioned bovine incisal edge fragments reattached using Gluma 2000 and Scotchbond 2. Teeth were sectioned 3 mm from the incisal edge using an Acutome with a 0.5 mm diamond wheel running at 90 degrees to the mesial or distal surface of the tooth. Twenty four incisal fragments were rebonded with each of the dentine bonding agents; a further 24 intact incisors were used as a control group. The control group required a mean fracture force of 940(+/- 144) N which was significantly greater (p < 0.01) than that required to fracture fragments rebonded using GLUMA 2000 (609 +/- 116) N and Scotchbond 2 (393 +/- 97) N. The mean force required to fracture incisal fragments rebonded with GLUMA 2000 was significantly greater (p < 0.01) than that required to fracture incisal fragments rebonded with Scotchbond 2.

Four hundred avulsed and replanted permanent incisors were examined for pulpal and periodontal healing. In 30 teeth, root formation was incomplete at the time of injury. Two teeth were excluded from the study due to nonphysiological extraalveolar storage (i.e. homemade saline). Of the 28 remaining replanted incisors, 7 showed subsequently completed root development, 8 partially completed root development and 13 arrested root development. Completed root development subsequent to replantation was found to be significantly related to pulpal revascularization, being rare in cases with pulp necrosis (5 of 15 teeth) and frequent after pulpal healing (11 of 13 teeth) (p = 0.01). Root development was not found to be significantly related to the extraalveolar storage period; but occurred slightly more frequently when the dry storage period was less than 45 min. (p = 0.13). Ingrowth of bone and formation of an internal periodontal ligament (PDL) was found in 6 teeth and was related to arrested root formation in cases with pulpal healing. The explanatory factor for these findings appeared to be damage to the Hertwig's epithelial root sheath.

Four hundred avulsed and replanted permanent teeth were examined for pulpal healing. In 110 teeth, the apical foramen was either open or half-open. In 16 teeth, the pulps were extirpated prophylactically. Thus, pulpal revascularization was considered possible in 94 teeth. Revascularization occurred in 32 teeth (34%). Pulp necrosis could usually be demonstrated after 3 weeks. Positive pulpal sensibility and radiographis signs of pulp canal obliteration were usually observed after 6 months. The effect of various clinical factors was examined, such as sex, age, type of tooth replanted, stage of root formation, type and length of extra-alveolar storage, clinical contamination of the root surface, type of cleansing procedure of the root surface, type and length of splinting and the use of antibiotics. Finally, the width of the apical foramen and the length of the root canal were measured on radiographs taken at the time of injury. A multivariate statistical analysis revealed that pulpal revascularization was more frequent in teeth with shorter distances from the apical foramen to the pulp horns. Furthermore, that wet storage (saliva and/or saline) for more than 5 min decreased the chance of pulpal revascularization; whereas dry extraalveolar storage had a monotonous effect on pulpal revascularization, i.e. decreasing chance of revasculatization with increasing length of the extraalveolar dry storage. Based on these findings, immediate replantation after brief cleansing in either tap water or saline is recommended.

A material of 322 patients with 400 avulsed and replanted permanent teeth were followed prospectively in the period from 1965 to 1988 (mean observation period = 5.1 yrs). The age of the patients at the time of replantation ranged from 5 to 52 yrs (mean = 13.7 yrs and median = 11.0 yrs). Standardized patient records were used through the entire period in order to obtain valid data concerning the extent of injury and treatment provided. At the follow-up period, pulpal and periodontal healing were monitored by clinical examination, mobility testing and standardized radiographic controls. Thirty-two of the replanted teeth (8%) showed pulpal healing. When related to teeth with incomplete root formation, where pulpal revascularization was anticipated (n = 94) the frequency of pulpal healing was 34%. Periodontal ligament healing (i.e. with no evidence of external root resorption) was found in 96 teeth (24%). Gingival healing was found in 371 teeth (93%). During the observation period, 119 teeth (30%) were extracted. Tooth loss was slightly more frequent in teeth with incomplete root formation at the time of replantation than in teeth with completed root formation.

400 avulsed and replanted permanent teeth were examined for periodontal ligament (PDL) healing, using standardized radiographic and clinical examination procedures (i.e. percussion test and mobility test). The effect of various clinical factors was examined, such as age and sex of the patient, type of tooth replanted, presence of crown fracture or bone fracture, stage of root development (including apical diameter and length of the pulp), type and length of extra-alveolar storage, clinical contamination of the root surface, type of root surface cleansing procedure, type and length of splinting period and antibiotic therapy. Surface resorption was generally diagnosed after 12 months; while inflammatory resorption and replacement resorption (ankylosis) were usually observed after 1 month and 1-2 months respectively. Most resorptive processes were diagnosed within the first 2-3 years. However, although rarely, even after 5 and 10 years new resorptive processes could be diagnosed. A univariate statistical analysis of 272 teeth revealed 9 factors significantly related to PDL healing. A subsequent multivariate analysis revealed that the following 4 factors had the strongest impact upon PDL healing, in descending order of significance: Stage of root development; length of the dry extra-alveolar storage period; immediate replantation and length of the wet period (saliva or saline storage). Nonphysiological storage, such as homemade saline and sterilizing solutions (chloramine and alcohol) always led to root resorption. Storage in tap water for more than 20 minutes usually led to root resorption. The common denominator for all these factors related to PDL healing appears to be survival of the PDL cells along the root surface. Based on these findings, immediate replantation is recommended irrespective of stage of root development.

Pulpal and periodontal tissues of immature incisors of 10 dogs were radiographically and histopathologically evaluated immediately, 7, 15, 30 and 60 days after experimental intrusion induced by mechanical blows. Forty upper central and mesial lateral incisors showing incomplete root formation on radiographs were submitted to intrusive force. After the observation periods, the dogs were killed, two at a time. The hemi-maxilas were removed and processed for histopathologic examination. The traumatized teeth showed accelerated apical formation with reduced radicular length. Pulpal vitality was maintained and the subjacent tissues did not present irreversible changes. All traumatized teeth re-erupted spontaneously.

Transient apical breakdown has been reported to occur in cases in which a periapical radiolucency develops and resolves without treatment following luxation injury. Diagnostic errors are inevitable if periapical breakdown is used as the sole criterion or as an overriding criterion in the decision to initiate root canal treatment. A clinical case report is presented in which transient apical breakdown occurred after a subluxation injury. The threshold to sensitivity tests increased yet sensitivity remained positive with the appearance of the periapical radiolucency. The decision was made not to initiate root canal treatment in spite of the radiographic appearance periapically. At the 10-month recall the tooth remained responsive to sensitivity tests and the apical radiolucency had disappeared.

Evidence of accidental damage to permanent incisor teeth was recorded as part of a national survey of adult dental health in Ireland. A total of 746 adults aged between 16 and 34 years were examined. The prevalence of injury was considerably higher in males and the majority of subjects in both sexes had just one tooth affected. There was a continuing increase in prevalence with age which appeared to level out after the age of 24. A high level of untreated injuries was noted in both age groups; of those injuries which were treated, composite restorations were more common in the younger age groups while extraction and replacement by a denture was more common in older subjects.

A case of an 8-year-old boy who met with a road traffic accident causing trauma to the body and face and extrusion of the upper central incisors is reported. Laceration, oedema and limited mouth opening indicated the use of general anesthesia. During intubation the right central was avulsed accidentally and the left central further luxated and rotated. The avulsed central was reimplanted and the other one derotated and stabilised with orthodontic wire and brackets. Twelve weeks later the patients teeth were firm, immobile, radiographically normal and responded positively to vitality test.

The case presented is a report of a healthy 11-year-old boy, who fell down and traumatized his four maxillary incisors. Both central incisors were deeply intruded with concomitant uncomplicated crown fractures, and both lateral incisors suffered concussion. The intruded teeth were repositioned using a removable orthodontic appliance and were endodontically treated 3 weeks after trauma. Tooth 11 became ankylosed 3 months post trauma, and tooth 21 was extruded to its original position after 5 months. Five months post-trauma, teeth 12 and 22 underwent necrosis and were endodontically treated. In addition, tooth 22 presented an external inflammatory root resorption that was arrested by calcium hydroxide paste after 3 months. A crown-lengthening procedure was performed on tooth 11 10 months post-trauma, exposing the clinical crown to a better condition for restoration. All 4 incisors were restored with a composite material, and the incisal edges of the central incisors were shaped at the same level. Two months after the crown lengthening procedure, spontaneous eruption occurred on tooth 11, that had been ankylosed. The restored incisal edge of tooth 11 was reduced to the same level of tooth 21. The patient is under periodical examination till a definitive orthodontic treatment can be performed.