Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent Teeth
Content
R E F E RE N C E M A N U A L
V 37 / NO 6
15/16
Guidelines for Guidelines fo r the th e Management of Traumati Traumaticc Dental Injuries: Injurie s: 1. Fractures and a nd Luxati Luxations ons of P er erm m anen an entt Teeth Originating Group International Association of Dental Traumatology
Endorsed ndorsed by th e American Academy of Pediatric Dentis try 2013
An tho ny j. DiA nge lis*1 • Jen Jens s 0. Andre asen *2 • Kurt A. Ebeleseder*3 • David J. Kenny *4 • Ma rtin Trop e*5 • Asgeir Sig urds son *6 • Lar Lars s Anderss on7 Cecilia Cec ilia Bourgui gnon 8 • Marie There Therese se Flores9 Flores9 • Morris Lamar Hicks10 • Anto nio R R.. L Lenzi enzi1 11 • Barbro Barbro Malmg ren12
Alex J. Moule 13 •
Yango Pohl1 Pohl14 •
Mits uhir o Tsukibosh i15
Abstract:
T r a u m a t ic ic d e n t a l i n ju ju r i e s ( T D Is Is ) o f p e r m a n e n t t e e t h o c c u r fr fr e q u e n t l y i n c h i l d r e n a n d y o u n g
a d u l ts ts . C r o w n f r a c tu tu r e s a n d l u x a t io io n s
a r e t h e m o s t c o m m o n l y o c c u r r in in g o f a l l d e n t a l in in j u urr ie ie s . P r o p e r di di a g gn n o s is is , t r e a t m e n t p l a n n i n g a n d ffo ollowup a
ffa a vo r a b l e
o u t co m e .
G u i d e lili n e s sh o u l d
a ssi ssist st d e n t i st s
and
patients
in
d e ci si o n
mak ing
a nd
for
prov iding
a r e im im p o r t a n t f o r i m p r o v i n g the
b e st
ca rre e
e f f e ct i ve l y
and
e f f iici ci e n tl tl y. T h e I n t e r n a t i o n a l A sso ci a t i o n o f D e n t a l T r a u m a t o l o g y ( I AD AD T ) h a s d e ve l o p e d a co n sen sen su s st a t e m e n t a f t e r a r e vi e w o f tth he d ental l i tte eratu re and g roup
d i scu scu ssi ssi on on s. E xp e r i e n ce d rre e se a r ch e r s a n d cl i n ici ici a n s f r o m
t h e d a t a d i d n o t a p p e a r co co n clu clu si v ve e , r e co m m e n d a t i o n s r e p r e se n t
the
b e st
cu r r e n t
e vi d e n ce
b a se d
on
va r i o ou u s sp e ci a l ttii e s w e r e i n cl u d e d i n t h e
g r o u p . I n ca se se s w h e r e e
w e r e b a se d o n t h e co n sen sen su s o p i n i o n o f t h e I A D T b o a r d m e m b e r s.
lili t e r a t u r e
se a r ch
and
p r o f e ssi o n a l
opinion.
The
prim ary
g oal
of
tth h e se
T h e g u i d e l iin nes
guidelines
is is
to o
d e l i n e a t e a n a p p r o a ch f o r t h e i m m e d i a t e o r u r g e n t car car e o f T D IIs. s. In In t h i s ffii r st a r ti ti cl e , t h e I A D T G u i d e lili n e s f o r m a n a g e m e n t o f f r a ct u r e s a n d l u xa t i o n s o f p e r m a n e n t t e e t h w i l l b e p re re se n t e d .
KEYWO RDS:
( D e n t a l T r a u m a t o l o g y 2 0 1 2 ; 2 8 :2 :2 - 1 2 ; d o i : 1 0 .l.l llll ii// jj.. 1 6 0 0 - 9 6 5 7 .2 .2 0 1 l . 0 ll1 1 0 3 . x)
C O N S E N S U S , F R AACC T U R E , L U X A T I O N , R EEVV IIEE W , T R A U M A , T O O T H
1Department o f Dentistr Dentistry, y, Hennepin County Medical Cent Center er and Uni versity of Minneso ta School o f Dentistry, Min neapolis, MN, USA USA;; 2Ce 2Center nter of Rare Oral Diseases, Department of Oral and Maxillofacial Surgery, Copenhagen University Hospital, Rigshopitalet, Denmark; department of Conservative Dentistry, Medical University Graz, Graz, Austria; 4Hospital for
A cce p t e d j a n u a r y 7 7,, 2 01 01 2 2..
Sick
Children
and
University
of
Toro Toronto, nto,
Toron Toronto, to,
Cana da;
de pa rtm ent of Endodontics, Endodontics, School of Dentist Dentistry, ry, Univer University sity of Pennsyl vania , Philadelph ia, PA, PA, USA; dep ar tm en t of Endodontics , UNC School of Dentistry, Chapel Hill, NC, NC, USA; USA; de pa rtm en t of Surgical Sciences, Faculty of Dentistry, Health Sciences Center Kuw ait University, Kuwait City, Kuwait; sPrivate Practice, Paris, France; 9Pediatric Dentistry, Faculty of Dentistry, Universidad de Valparaiso, Valparaiso, Chile; Chile; wDepar tment of Endodontics, University University of Maryland School of Dentistry, Dentistry, Baltim Baltimore, ore, MD, MD, US USA; A; u Private Practice, Practice, Rio de Janeiro, Brazil; 12Depart ment of Clinical Sciences Intervention and Technology, Division of Pediatrics, Karolinsk a University Hospital, Hospital, S tockhol m, Sweden; 13Private Practice, Practice, University of Queensland, Brisbane, Austr alia; 14Departm ent of Oral Surgery, Surger y, University of Bonn, Bon n, Germany;
'Private Practic Practice, e, Amag un,
Aichi, Japa n. Correspondence to to An tho ny J DiAngelis. DiAngelis. DMD, DMD, MPH, MPH, Henne pin Coun ty Medical Center, Center, 701 701 Par Parkk Ave nue South .Minnea polis, MN ggqig, USA. Tel.: 612 Spy -6t7y Fax: 612-gog-gyig e-mail: [email protected] * Members
of the Task Gro Group. up.
W h e n e v e r r e f e r r in in g (Dent
Trau m atol
to
I A D T G u i d e llii n e s , th th e
2 0 1 2 ;2 ;2 8 : 2 2-- 1 2) 2)
should
o r i g i n a l a r t i c lle e ,
always
be
used
a s
Traumatic dental injuries (TDIs) occur with great frequency in preschool, school-age children, and young adults comprising 5% of all injuries for which people seek treatment (1, 2). A 12-year review of the literature reports that 25% of all schoo schooll children experi experience ence denta dentall trauma and 33% of adults have experienced trauma to the permanent dentition, with the majority of injuries occurring before age nineteen (3). Luxation injuries are the most common TDIs in the primary dentition, whereas crown fractures are more commonly reported for the permanent dentition (1, 4, 5) TDIs present a challenge to clinicians worldwide. Consequently, proper diagnosis, treatment planning and follow up are critical to assure a favorable outcome. Guidelines, among other things, should assist dentists, other healthcare professionals, and patients in decision making. Also, they should be credible, readily under standable. and practical with the aim of delivering appropriate care as effectively and efficiently as possible. The following guidelines by the International Associ ation of Dental Traumatology (IADT) represent an updated set of guidelines based on the original guidelines published in 200 2007 7 (6-8). The upda te was accomplished by doing a review of the curren t denta l liter ature using EMBASE. MEDLINE, and PUBMED searches from 1996 to 2011 as well as a search of the journal of Dental Traumatology from 2000 to 2011. Search words included tooth fractures, root fractures, tooth luxation, lateral luxation and permanent teeth, intruded permanent teeth,
reference.
and luxated permanent teeth. Copyright © 2012 2012,, International Association Association of Dental Traumatology, w w w . i a d t - d e n t a l t r a u m a . o r g . 2012;28:2-12; 2-12; doi: I0.l11 I0.l111/j 1/j.1600 .1600-965 -9657.20 7.2011.01 11.01103. 103.x. x. Reprinted Reprinte d wi th permission of the Intern ational Association of Dental Traumatology (IA (IADT DT). ). De ntal Trau ma tology 2012;28: Av ai la bl e a t http://onl i nel i brary.wi l ey.eom /doi /10.i ni /J.l 600-9657.201l .DH03.x/ful.l
322
ENDORSEMENTS
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. It is understood that subsequent treatment may require secondary and tertiary interventions involving specialist consultatio ns, services, services, an d/o r materials method s not always available to the primary treating clinician. The IADT published its first set of guidelines in 2001 and updated them in 2007 (6-13). As with the previous guidelines, the working group included experienced investigators and clinicians from various dental specialties and general practice. This revision represents the best evidence based on the available literature and expert profes siona l judg me professiona ment. nt. In cases where the da data ta did not appear conclusive, recommendations are based on the consensus opinion of the working group followed by review revi ew by the members of the IADT Board o f Directors. It is understood that guidelines are to be applied with evaluation of the specific specific clinica clinicall circumsta nces, clinicians’ judg me ment, nt, and pat patien ien ts’ characteristic characte ristics, s, including but not limited to compliance, finances, and understanding of the immediate immedi ate and long-term long-term outcomes of treatment a lterna tives versus non-treatment. The IADT cannot and does not guarantee favorable outcomes from strict adherence to the Guidelines, but believe that their application can maximize the chances of a favorable outcome. Guidelines undergo periodic updates. These 2012 Guidelines in this journal will appear in three parts: Part I: F ractures and luxations o f perman ent teeth Part II: Avulsion of permanent teeth Part III: Injuries in the primary dentition Guidelines offer recommendations for do diagnosis and treatment of specific TDIs; however, they not provide the comprehensive nor detailed information found in textbooks, the scientific literature, and, most recently, the Dental Trauma Guide (DTG) that can be accessed on http://www.dentaltraumaguide.org.. Additionally, the http://www.dentaltraumaguide.org DTG, also available on the IADT’s web page http:// www.iadt-dentaltrauma.org,, provides a visual and ani www.iadt-dentaltrauma.org mated doc umentation o f treatment procedures as well well as estimations of prognosis for the various TDIs. Genera Generall recommendations/considerations Clinical examination
Detailed description of protocols, methods, and docu mentation for clinical assessment of TDIs can be found in current textbooks (1, 14, 15). Radiographic examination
Several projections and angulations are routinely rec ommended, but the clinician should decide which radio graphs are required for the individual. The following are suggested: • Periapical radio graph with a 90° 90° horizont al angle with with central beam through the tooth in question. • Occlusal view view.. • Periapical radio graph with lateral angula tions from from the mesial or distal aspect of the tooth in question. Emerging imaging modalities such as cone-beam computerized tomography (CBCT) provide enhanced visualization of TDIs, particularly root fractures and lateral luxations, monitoring of healing, and complica tions. Availability is limited, and its use not currently considered routine; however, specific information is available in the scientific literature (16, 17).
Splinting type and duration
Current evidence supports short-term, non-rigid splints for splinting of luxated, avulsed, and root-fractured teeth. While neither the specific type of splint nor the duration of splinting for root-fractured and luxated teeth are significantly related to healing outcomes, it is considered best practice to maintain the repositioned tooth in correct position, provide patient comfort and improved function (18, 19). Use of antibiotics
There is limited evidence for use o f systemic systemic antibiotics in the management of luxation injuries and no evidence that antibiotic coverage improves outcomes for rootfractured teeth. Antibiotic use remains at the discretion of the clinician as TDI’s are often accompanied by soft tissue and other associated injuries, which may require other surgical intervention. In addition, the patient’s medical status may warrant antibiotic coverage (19, 20). Sensibility tests
Sensibility testing refers to tests (cold test and/or electric pulp test) atte mpting mp ting to determine dete rmine the conditio cond ition n of the pulp. At the time of injury, sensibility tests frequen tly give no response indicating a transient lack of pulpal response. Therefore, at least two signs and symptoms are necessary to make the diagnosis of necrotic pulp. Regular follow up controls are required to make a pulpall diagnosis. pulpa Immature versus mature permanent teeth
Every effort should be made to preserve pulpal vitality in the immature permanent tooth to ensure continuous root development. The vast majority of TDIs occur in children and teenagers where loss of a tooth has lifetime consequences. The immature permanent tooth has considerable capacity for healing after traumatic pulp exposure, expos ure, luxa tion injury, and root fractur es. Pulp exposures secondary to TDIs are amenable to proven conservative pulp therapies that maintain vital pulp tissue and allow for continued root development (21 24). In addition, emerging therapies have demonstrated the ability to revascularize/regenerate vital tissue in canals of immature permanent teeth with necrotic pulpss (25-30). Teeth frequently pulp freque ntly sustain sust ain a combina com bina tion of several injuries. Studies have demonstrated that crown-fractured teeth with or without pulp exposure and associated luxation injury experience a greater frequency of pulp necrosis (31). The mature permanent tooth that sustains a severe TDI after which pulp necrosis is anticipated is amenable to preventive pulpectomy pulpec tomy as root ro ot development develo pment is subs tantially tant ially com com pleted. Pulp canal canal obliteration
Pulp canal obliteration (PCO) occurs more frequently in teeth with open apices which have suffered a severe luxation injury. It usually indicates ongoing pulpal vitality. Extrusion, intrusion, and lateral luxation injuries have high rates of PCO (32, 33) Subluxated and crownfractured teeth also may exhibit PCO. although with less frequency (34). Additionally, PCO is a common occur rence following root fractures (35, 36).
Copyright © 20 2012 12,, International Association Association of Dental Traumatology, w w w . i a d t - d e n t a l t r o u m a . o r g . 10.1111/j. 1/j.1600-965 1600-9657.2011. 7.2011.01103.\ 01103.\.. Reprinted with permission of the Inte rnational Association of Dental Traumatology (IA (IADT DT). ). De nta l Tra um ato log y 2012;28:2-12 ; do i: 10.111 Av ai la bl e a t http://onli http://onlinelibrary.wiley.eom/doi/ nelibrary.wiley.eom/doi/10.1111/j.l600-9657.2011.01103.x/full 10.1111/j.l600-9657.2011.01103.x/full..
ENDORSEMENTS
323
REFERENCE MA NU AL
V 37 I NO 6
15 /16
Permanent teeth
1 . T r e a t m e n t g u i d e l i n e s f o r f r a c t u r e s o f ttee e t h a n d a l v e o l a r b o n e
C l i n iicc a l f i n d i n g s In f r a c t i o n
E n a m e l f r a c ttuu r e ^ *
^ j f f m
y
y
1 \1 M 11 I I f
Radiographic findings
Treatm ent
Follow-up procedures for fractures of teeth a nd n d a lvlv e ol ola r b o n e 1
F a v o r ab a b l e a n d u n f a v o r a b llee o u t c o m e s i n c l u d e s o m e , b u t n o t n e c e s s a r i llyy a l l,l , o f t h e f o llll o w inin g
Follow up
F a v o r ab ab l e o u t c o m e
Unfavorable outcom e
A n in c o m p le te f r a c t u r e ( c r a c k ) o f
No radiographic abnormalities
In case of marked i n f r a c t i o n s ,
No fol l ow up i s generally needed
A s y m p t o m a t i c P osi ti ve response
S y m p t o m a t i c Negati ve response
t h e e n a m e l w i t h o u t l o s s o f tooth structure N o t t e n d e r . I f t e n d e r n e s s i s o b s e r v e d e v a l u a t e , t h e t o o t h f o r a possible luxation injury or a root fracture
Radiographs r e c o m m e n d e d : a p e r i a p i c a l v i e w . Additional radiographs are i n d i c a t e d i f o t h e r s i g n s o r symptoms are present
etching and sealing with resin t o p r e v e n t d i s c o l o r a t i o n o f the infraction l i n e s ; o t h e r w i s e , no treatment i s necessary
for infraction injuries unless they are a s s o c i at at e d w i t h a l u x a t i o n i n j u r y o r o t h e r f r a c ttuu r e types
to pulp testing C o n t i n u i n g r o o t d e v e l o p m e n t i n i m m a t u r e t e eett h
• Enam el loss is visible • Radiographs recommended: visible sign of periapical, exposed dentin occlusal, and • N oott t e n d e r . I f t e n d e r n e s s is e c c e n t r ic exposures. They o b s eerr vvee d , e vvaa lluu a ttee t h e t o oott h f o r a ar e r e c o m m e n d e d in order to rule possible luxation or out the possible root fracture injury presence of a • N o r m a l m o b i l itit y root fracture or a • S e n s i b i l i tyty p u l p t e s t luxation injury u s u a l l y p o s i t iivv e • R a d i o g r a p h o f l ipip or cheek to search for tooth fragments or foreign materials
• I f t h e ttoo o t h fragment is available, it can be bonded to the tooth • C o n t o u r inin g o r restoration with composite resin depending on the extent and location of the fracture
to pulp testing S i gns of api c al periodontitis N o c o n t i n u i n g r o o t d e v e l o p m e n t i n i m m a t u r e t e e tthh E n d o d o n t i c therapy appropriate for stage of root d e v e l o p m e n t i s indicated S y m p t o m a t i c Negati ve response to pulp testing S i g n s o f a p i c a l periodontitis No continuing root development in i m m a t u r e t e eett h E ndodonti c therapy a p p r o p r i a te t e f o r stage of root d e v e l o p m e n t i s indicated
• A c o m p l e t e f r a c ttuu r e of the enamel • L o s s o f e n a m e l. N o
6 - 8 w e e kkss C " 1 y e a r C ++ ++
• A s y m p t om o m a t iicc • P o s i t iivv e r e s p o n s e to pulp testing • C o n t i n u ini n g r o o t development in i m m a t u r e t e e tthh • C o n t i n u e t o n eexx t evaluation
C o p y r i g h t © 2 0011 2 , IInn t e r n a t i o n a l A s s o c i a tit i o n o f D e n t a l T r a u m a t o l o g y , www.iadt-dentaltrauma.org www.iadt-dentaltrauma.org.. R e p r i n t e d w i t h p e r m i s s ioi o n o f t h e I n t e r n a t iioo n a l A s s o c i at a t iioo n o f D e n t a l T r a u m a t o l o g y ( IA I A D T ) . Dent al Tr Traumat aumat ology ol ogy 2012;28:2-12; 12;28:2- 12; doi: doi : 10.1111/j.1600-9637.2011.01103.x. Available Ava ilable at htt p://onli nelibrary.wiley.eom/doi/1 nelibrary.wiley.eom/doi/10.llll/j.1600 0.llll/j.1600-96 -9657. 57.201 2011.0 1.0ll03.x/full. ll03.x/full. 324
ENDORSEMENTS
A M E R I C A N A C A D E M Y O F P E D I A T R IIC C DENTISTRY
(Continued) Follow-up procedures for Favorable Favorable and unfavorab unfavorable le outcomes fractures o f teeth include some, but not necessarily all, of the and alveolar bone1 following
1. Treatment guidelines for fractures of teeth and alveolar bone
Clinicall findings Clinica Enamel-dentin fracture
Radiographic findings
A fracture confined confined • Enamel-dentin to enamel and loss is visible
Unfavorable outcome
6-8 weeks C** 1 y ea ea r C "
• Asymptomatic • Positive response to pulp testing • Continuing root development in immature teeth teeth • Continue to next evaluation
• Symptomatic • Negative response to pulp testing • Signs of apica apicall periodontitis • No continuing root development in immature teeth • Endodontic therapy appropriate for stage of root development is indicated
6-8 weeks C+* 1 ye year ar C C** **
• Asymptomatic • Positiv Positivee resp response onse to pulp testing • Continuing root development in immature teeth teeth • Continue to next evaluation
• Symptoma Symptomatic tic • Negative response to pulp testing • Signs of apica apicall periodontitis • No continuing root development in immature teeth • Endodontic therapy appropriate for stage of root development is indicated
Follow up
• If a tooth fragment is available, it can
dentin with loss loss of • Radiographs tooth structure, but recommended: not exposing the periapical, pulp occlusal, and Percussion test: eccentric not tender. If exposure to rule tenderness is out tooth observed, evaluate displacement or the tooth for possible presence possible luxation of root fracture or root fracture • Radiograph of lip injury or cheek Normal mobility lacerations to Sensibility pulp test search for tooth usually positive fragmentss or fragment • foreign materials
Enamel-dentin-pulp fracture
Favorable outcome
Treatment
be bonded to the tooth. Otherwise, perform a provisional treatment by treatment by covering the exposed dentin with glass lonomer or a more permanent restorati restoration on using a bonding agent and composite resin, or other accepted dental restorative materials If the exposed dentin is within 0.5 mm of the pulp (pink, no bleeding), place calcium hydroxide base and cover with
a material such as a glass ionomer A fracture involving • Enamel-dentin • In young patients enamel and dentin loss visible with immature, still with loss of tooth • Radiographs developing teeth, it structure and recommended: is advantageous to exposure of the periapical, preserve pulp vitality pulp. occlusal, and by pulp capping or Normal mobility eccentric partial pulpotomy. Percussion test: exposures to Also, this treatment not tender. If rule out tooth is the choice in young tenderness is displacement or patients with observed, evaluate possible presence completely formed for possible of root fracture teeth luxation or root • Radiograph of lip • Calcium hydroxide is a fracture injury or cheek suitable material to be Exposed pulp lacerations to placed on the pulp sensitive to stimuli search for tooth wound in such fragments or procedures foreign materials • In patients with mature apical development, root canal treatment is usually the treatment of choice, although pulp capping or partial pulpotomy also may be selected If tooth fragment is available, it can be bonded to the tooth Future treatment for the fractured crown may be restoration with other accepted dental restorative materials
Copy right © 2201 012, 2, Internationa l Association o f Dental Traum atology, www.iodt~dentoltrouma.org. Reprinted with permission o f the In ternationa l Associati Association on o f Dental Traumatology (IAD (IADT). T). Dental Traumatology 2012:282-12; 2012:282-12; doi: 10.im/j.1600-9657 10.im/j.1600-9657.201l.0l10 .201l.0l103.x. 3.x. Availab Ava ilable le at at http://onlinelibrary.wiley.eom/doi/10.WI/j.l600-9657.201l.0m3.x/full http://onlinelibrary.wiley.eom/doi/10.WI/j.l600-9657.201l.0m3.x/full. ENDORSEMENTS
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R EF EF E ER R EN EN C E M A N U A L
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6
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(Continued) Follow-up procedures for Favorable Favorable and unfavorable outcomes fractures of teeth include some, but not necessarily all, of the and alveolar bone1 following
1. Treatment guidelines for fractures of teeth and alveolar bone
Clinical findings C ro w n -ro o t fra ctur e w it h o u t pul p ex p os ur e
i l l i f
la
V 1 V
Radiographic f i n d in g s
T r ea t m e n t
Follow up
6- 8 weeks C** • A f r a ct u r e • A pical extensi on Emergency treatment • As an emerge emergency ncy 1 year C” invo lvin g enamel, o f f r a ct u r e us ually no not t re a t m e n t , a t e m p o ra r y dentin, and stabilization of the loose c em entum wi th v i s i bl e segment to adjacent teeth l os s o f t o o t h • R ad i ogr aphs can be performed until a stru struct ctuu re re , h ut ut nnoo t re reco com mm mee nndd ed ed : d efinitiv e tr e atm e nt plan is e xp xp osi osinn g tthh e pu pu llpp p eeri riaa ppii ccaa ll,, made • Crown fra ctu re occlusal, and Non-emergency treatment extending be below ec cceentric alternatives gingiv al al margin exposur es es. • Percussion test: They are Fr agment r emoval only • Removal of the coronal t en d e r r e c om m en de d crown-root fragment and • Co rroonal f rraa gm gm eenn t t o det eecc t subsequent restoration of m o bi l e fra c tu re lines • Sens ibility pulp i n t he r o o t t h e api c al f r a g m e n t exposed above the test usually gingival level positive for apical Fragment removal and fragment gingivectomy (sometimes ostectomy) • Removal of the coronal crown-root segment with
•
•
•
•
Favorable outcome
Unfavorable outcome
• A s ym ym pt ptom at atic • Pos Posititive ive res respo ponse nse to pulp testing • C on o nt i n u i n g r o o t de devel velopme o pment nt in im ma ma tu ture teeth • C o nti n ue t o nex t evaluation
• S yym mp to toma titic • Ne Nega gatitive ve response to pulp t e s t i ng • Si Sign gnss of apic apical al p eerrio ddoo nnttitis • No continui continuing ng root development in immature teeth • Endodontic therapy appropriate for stage of root development is indicated
subsequent endodontic treatment and restoration with a post-retained crown. This procedure should be preceded by a gingivectomy, and sometimes ostectomy with osteoplasty Orthodontic extrusion of apical fragment Removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown Surgical extrusion Removal of the mobile fractured fragment with subsequent surgical repositioning of the root in a more coronal position Root submergence Implant solution is planned Extraction Extraction with immediate or delayed implant-retained crown restoration or a conventional bridge. Extraction is inevitable in crown-root fractures with a severe apical extension, the extreme being a vertical fracture
www.iadt-dentaltrauma.org.. Cop yright © 201 2012, 2, Internation al Association o f Dental Traumatolog y, www.iadt-dentaltrauma.org 2012;28:2-12; doi: 10.l1l1/j.160 10.l1l1/j.1600-965 0-9657.201 7.201l.0ll03.x. l.0ll03.x. Reprinted with permission of the international Association of Dental Traumatology (IADT). Dental Traumatology 2012;28:2-1 Availab Ava ilable le at at http://onlinelibrary.wiley.eom/doi/10.ini/j.1600-9657.2011.01103.x/full http://onlinelibrary.wiley.eom/doi/10.ini/j.1600-9657.2011.01103.x/full. 326
ENDORSEMENTS
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
(Continued) Follow-up procedures f o r f r a c ttuu r e s o f te e th a n d a l v e o la r b o n e 1
F a v o ra b le a n d u n fa v o ra b le o u tc o m e s in c lu d e s o m e , b u t n o t n e c e s s a rily a ll, of the following
Treatment
Follow up
Favorable outcome
Un fa v o ra b le outcome • Symptomatic
1 . T re a tm e n t g u id e lin e s fo r fra c tu re s o f te e th a n d a lv e o la r b o n e Clin ic a l findings
Radiographic findings
Crown-root
• A frfr a c t u r e
• A p ic a l
E m e r g e n c y t r e a t m en en t
6 - 8 w e e ks ks C "
• Asymptomatic
fra c tu re with pulp exposure
involving e n a m e l, d e n tin , and cementum and exposing th e pulp • Percussion te s t: te n d e r • Coronal fragment m o b ile
e x te n s io n o f fra c tu re u s u a lly n o t visible • Radiographs recommended: p e ria p ic a l a n d o c c lu s a l exposure
• As an emergency treatment a temporary stabilization of the lo o s e s e g m e n t to a d ja c e n t te e th • In p a tie tie n ts with o p e n a p ic e s , it is a d v a n ta g e o u s to p re s e rv e p u lp v ita lity b y a p a rtia l pulpotomy. This treatment is also the choice in young patients with completely formed te e th . Ca lc iu m h y d ro x id e compounds are suitable pulp c a p p in g m a te ria ls . In p a tie n ts with mature apical development, ro o t c a n a l tre a tm e n t c a n b e th e treatment of choice Non-Emergency Treatment Alte rn a tiv e s Fragment removal and gingivectomy (sometimes osteotomy)
1 year C+*
• P o s i titi v e • N e g a t iivv e re s p o n s e to response to p u lp te s tin g p u lp te s tin g • Continuing root • Sig n s o f development a p ic a l in immature periodontitis teeth • No continuing • Continue to root development n e x t e v a lu a tio n in im m a tu re te e th • Endodontic therapy appropriate for s ta g e o f ro o t development is in d ic a te d
ii&A V
,*V / m r '1 v
1 '
Removal of the coronal fragment with subsequent endodontic treatment and restoration with a post-retained crown. This p ro c e d u re s h o u ld b e p re c e d e d b y a gingivectomy and sometimes osteotomy with osteoplasty. This treatment option is only indicated in crown-root fractures with p a la ta l s u b g in g iv a l e x te n s io n Orthodontic extrusion of apical fragment Removal of the coronal segment with subsequent endodontic treatment and orthodontic extrusion of the remaining root with sufficient length after extrusion to support a post-retained crown Su rg ic a l e x tru s io n fRr ea m g mo ve an lt owfi t thh es umb os be iql ue efnr ta cstuurrgeidc a l repositioning of the root in a more c o ro n a l p o s itio n Root submergence An im p la n t s o lu tio n is p la n n e d , th e r o o t f r a g m e n t m a y b e l e f t in situ situ Ex tra c tio n Extraction with immediate or delayed implant-retained crown re s to ra tio n o r a c o n v e n tio n a l b rid g e . Ex tra c tio n is in e v ita b le in very deep crown-root fractures, th e e x tre m e b e in g a v e rtic a l fra c tu re
Copyright © 20 2012 12,, International Association Association of Dental Traumatology, www.iadt-dentaltrauma.org www.iadt-dentaltrauma.org.. Reprinted with permission of the Inter national Association of Dental Traumatology (IADT). (IADT). Den tal Tra umatol uma tology ogy 2012;28 2012;28:2-12; :2-12; d doi: oi: 10.l111/].1600-965 10.l111/].1600-9657.201 7.201l.0110 l.01103.x. 3.x. Available a t http://onlinelibrary.wiley.eom/doi/10.im/j.1600-9657.20ll.0m3.x/full . ENDORSEMENTS
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(Continued) Follow-up procedures for luxated permanent teeth
2. Treatment guidelines for luxation injuries
Root fracture
Clinical Clinic al findings
Radiographic findings
Treatment
Follow up
Favorable outcome
Unfavorable outcome
• T he he c orona l
• T hhee fr a ctu r e
• Reposition, if
4 weeks S4, C44
• Positive response response
• Symptomatic
•
•
•
•
•
s eg egm en ent ma ma y be i nv nv ooll ve ves th e ro oott m ob ob ilile and ma may o f the t oo oo th th aannd be di splaced i s i n a h o r i z o n t al or oblique plane The tooth may bbee • Fr Fraa cctt ure uress t ha ha t a re re tender to per cu ss ion i n t h e h o r i z on t al B le leed ing f ro ro m t he he p la lan e c an an uuss ua ual llyy be de dete tect cted ed in the the gingival sulcus may be noted r e gul ar per iapical S en en si si bi bi lili ty ty t es es titi ng ng 9 0° 0° aann gl gl e f ilil m with the central may give negative b ea ea m t hro hrouu g h t he he results initially, i nd i c a t i n g to o th . T h is is tr a n s i e n t o r us uall y the case p erm ermaa ne ne nt nt n eu eu ra ra l w ith ith f ra ra cctt ure uress in the cervical third damage M o n i t o r i n g t he o f t h e ro o t stat status us of the pul pulpp • If the plane plane of i s r ec ec om om me me nd nd ed ed f ra ra ct ct ur ur e i s m or ore oblique, which is Transient crown d is is ccoo lo lo ra ra titi on on ((rr ed ed or gray) may o c cu r
Alveolar fracture
Favorable and unfavorable outcomes include some, but not necessarily all, of the following2
• The fracture i n v o l v e s t he alveolar bone and m a y e x te n d t o adjacent bone • Segment mobility and di sl sl oc oc aatti on on with several teeth mo vviing t og og eetth eerr are c o m m o n findings • An occlusa occlusall change because o f m is is aalli gn gnm en ent the fractured a lv lv eo eo la r s eg eg me me nt nt is often noted • Sensibility testing may or may not be positive
• •
•
•
d iissplaced, t he he c oorronal segment of the tooth as s o on as as pos sible Check position rad rad io io ggra rapp hic hicaa lly lly Stabilize the tooth w iitt h a f le le xi xi bbll e s pl pl iinn t for 4 week weeks. s. IfIf the the root fracture is near the cervical area of the tooth, stabilization is b en en ef ef ici iciaa l f o r a longer period of time (up to 4 months) It is advisable to monitor healing for at least least 1 year year to determine pulpal status If pulp necrosis
c om om m moo n w itit h develops, root canal treatment of the apical third coronal tooth fr a c tu re s, an segment to the occlusal view or fracture line is radiographss with radiograph indicated to preserve varying horizontal the tooth angles is more likely to demonstrate the fracture including those located in the middle third • Reposition any • Fracture lines displaced segment may be l ocated at and then splint any level, from th e m a rg in al bone • Suture gingival laceration if present to the root apex • In addition to the • Stabilize the segment for 4 weeks 3 a nngg uulla titi oonns and occlusal film, a dddd iittio nnaa l vi views s u c h as a panoramic radiograph can be helpful in d eette rm rm iinn iinn g t he he course and p ooss itit io io n o f t he he fracture lines
6 -8 -8 we weeks C44 4 m oonn tthh s S44, C44 6 months C44 1 ye year C44 5 year s C44 •
to ppuu lp te s tin g ( ffaalse negative p o s si b le u p t o 3 m o nth s ) S igns o f repai r between fractured s e gm e nt s • Continue Continue ttoo next evaluation
4 weeks S4, C44 6-8 weeks C44 4 months C44 6 months C44 1 year C C444 5 years C44
• Negative res ppoonse to pul p t e sti n g ((ffalse negative possible up to 3 months) • Extrusion of the c o ro n a l se g m e n t • Radiolucency at the fracture line • Clinical signs of periodontitis or abscess associated with the fracture line • Endodontic therapy appropriate for stage of root development is indicated
• Posit Positive ive resp respon onse se • Symptom Symptomati aticc • Negativ Negativee to pulp testing response to pulp (false negative p o s s i b l e up t o te s tin g ((ffal se negative possible 3 months) up to 3 months) • No signs of apica apicall • Signs of aapica picall periodontitis periodontitis or • Continue Continue to nnext ext evaluation
external inflammatory root resorption • Endodontic therapy appropriate for stage of root development is indicated
Copyright © 20 2012 12,, International Associati Association on of Dental Traumatology, www.iadt-dentaltrauma.org www.iadt-dentaltrauma.org.. Reprinted Reprinte d w ith permission of the International Association o f Dental Traumatology (IADT) (IADT).. Denta l Traumatol ogy 2 2012;2 012;28:2-12 8:2-12;; do i: I0.1l1l/j.1600-9657.2011.0n03.x. Available at http://onlinelibrary.wil http://onlinelibrary.wiley.eom/doi/l0.l ey.eom/doi/l0.llll/j.l lll/j.l600-9657.20ll.0H03.x/ 600-9657.20ll.0H03.x/full full. 328
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A M E R I C A N A C A D E M Y O F P E D I A T R IIC C DENTISTRY
(Continued) Follow-up procedures for luxated permanent teeth
2. Treatment guidelines for luxation injuries
Clinical Clinic al findings
Radiographic findings
Treatment
Follow up
Concussion
The tooth is tender to touch or tapping; it has not been displaced and does not have increased mobility Sensibility tests are likely to give positive results
• No radiographic radiographic abnormalities
• No treatment is needed • Monitor pulpal condition for at lea least st 1 year year
4 weeks weeks C " 6-8 weeks C"* 1 year C* C*++
Subluxation
The tooth is tender to touch or tapping and has increased mobility; it has not been displaced Bleeding from
• Radiographic abnormalities are usually not found
• Normally Normally no treatment is needed; however. a flexible splint to stabilize the tooth for patient comfort can be used for up to 2 weeks
2 weeks weeks S\ C** 4 weeks C** 6-8 weeks C** 6 months C*+ 1 y ea ea r C "
• Increased periodontal ligament s pac e a p i c a l l y
• Reposition Reposition th thee 2 weeks weeks S*1C " tooth by gently 4 weeks C*+ re-inserting It into 6-8 weeks C** the to ot oth ssoocket 6 months months C " • Stabilize the tooth 1 year Ct Ct++ for 2 weeks using Yearly 5 years C” a flexible splint
gingival crevice may be noted Sensibility testing may be negative initially indicating transient pulpal damage Monitor pulpal response until a definitive pulpal diagnosis can be made Extrusive luxation
The tooth appears elongated and is excessively mobile Sensibility tests will likely give negative results
• In mature teeth where pulp necrosis is anticipated or if several signs and symptoms indicate that the pulp of mature or immature teeth became necrotic, root canal treatment is indicated
Favorable and unfavorable outcomes include some, but not necessarily all, of the following2 Favorable outcome
Unfavorable outcome
• Asympt Asymptomatic omatic • Positive response to pulp testing • False negative possible up to 3 months • Continui Continuing ng roo roott development in immature teeth • Intact lamin laminaa du dura ra
• Symptomatic • Negative response to pulp testing • False negative possible up to 3 months • No continuing root development in immature teeth, signs of apical periodontitis • Endodontic therapy appropriate for stage of root development is indicated • Asymptomatic • Symptomatic • Positive response • Negative response to pulp testing to pulp testing • False negative • False False negative negative possible up to possible up to 3 months 3 months • Continuing root • External development in inflammatory immature teeth resorption • Intact lamina dura • No continuing root development in immature teeth, signs of apical periodontitis • Endodontic therapy appropriate for stage of root development is indicated • Asymptomatic • Symptoms and • Clinic Clinical al aand nd radiographic sign radiographic consistent with signs of normal apical periodontitis or healed • Negative response periodontium to pulp testing • Positive response (false negative to pulp testing (false negative possible up to 3 months) • Marginal bone height corresponds to that seen r ad adio gr gr ap aphic al al llyy after repositioning • Continuing root development in immature teeth
possible up to 3 months) • If breakdo breakdown wn of marginal bone, splint for an additional 3-4 weeks • External in flfl am am m maa to to ry ry ro ro ot ot resorption • Endodontic therapy appropriate for stage of root development is indicated
Copyright © 2012 2012,, International Association Association of Dental Traumatology, www.iadt-dentaltraumo.org www.iadt-dentaltraumo.org.. Reprinted with permission of the Intern ational Association of Dental Traumatology (IAD (IADT). T). Dental Traumatology 201228:2-12: doi: 10.li 10.li ll /j . 1600-9657.2011.0 1600-9657.2011.0110 1103.x. 3.x. Ava ilab le a t http://onlinelibrary.wiley.eom/doi/10.llll/j.1600-96572011.01103.x/full . ENDORSEMENTS
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V 3 7 I N O 6
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(Continued) Follow-up procedures for luxated permanent teeth
2. Treatment guidelines for luxation injuries
l in ic al al f in di din gs gs
Radiographic f in in di di ng ng s T he w i d e n e d per perio iodon donta tall li ga ga me me nt nt ssppace is b est seen on e c ce n t r ic o r oc c l u s a l e x p o s u r es
T r e at m e nt
Fo ll ow up
• R ep epos itition the to ot oth d i g i t a ll y o r w i t h f or or ce ce ps ps t o ddiis en en ga gag e i t fr o m itits b o ny l oc k an d g e n t l y r e p o s it io n i t in t o i ts o ri g ina l loc at ion • Stabi lize th e to o th for 4 weeks using a f l e xi b le s p l in t • Monitor the pulpal pulpal c o n d it i o n • If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption
2 weeks S4, C44 4 weeks C44 6 --88 we weeks C44 6 m o n th s C44 1 y ear C44 Year ly f o r 5 years C44
Lateral Luxation
Th e to ot oth is • disp displa lace ced, d, usua usuallllyy in a pa pal at at al al/l in ing ua ua i or labial direction It w il l be im m o b ile and p e r cu ss io n usually gives a high, metallic ( a n k y l o t i c ) s ou n d Fracture of the alveolar process present Sensibility tests will likely give negative results
Intrusive luxation
The to ot oth is is • The per io iod on on ta tal d isp ispll aace cedd a xi xiaa lllly l ig ig am am en en t sp sp ace ace
Teeth with incomplete root f o r m a t io n
2 weeks S4, C44
i nntt o t he he al al ve ve ol ol ar ar m ay ay be be ab ab se se nt nt from all or part bone I t is i m m moobi le, o f th e r o o t and percussion • The c ement oenamel junction may give a high, is located more metallic (an (ankyl kyloti otic) c) ssou ound nd api apical cally ly in the the S en en si si bi bil itit y te te st st s in trtr ud ud ed ed t oo oo th th than in adjacent will likely give non-injured teeth, negative results at times even apical to the marginal bone level
• Allow eruption without i n t e r v e n t io n • I f n o m ov ov em em en en t w itit hi hin fe w weeks, ini tia te ort orthodon hodonti ticc repo reposit sitio ioni ning ng • If ttooth ooth is intruded intruded mor moree than 7 m m , re pos itio n surgically or orthodontically Teeth with complete root formation • Allow eru eruption ption without intervention if tooth intruded less than 3 mm. If no movement after 2-4 weeks, reposition surgically or orthodontically before ankylosis can develop If tooth is intruded beyond 7 mm, reposition surgically The pulp will likely become
4 weeks C44 6 - 8 weeks C44 6 m on on th th s C44 1 year C44 Ye Year arly ly for 5 years C44
Favorable Favorable and unfavorable outcomes include some, but not necessarily all, of the follow ing2 Favorable o utc om e
Unfavorable o utc om e
• • Asymptomatic • Cl Cli ni cal and r a d io g r a p h i c s ig n s o f nor mal • o r healed p er er iioo do do nt nti u m • P os itiv e res ponse t o p u l p t e s t i ng (false negative •
Symptoms and radiographicc signs radiographi consistent with apical periodontitis Negative response to pulp te ssttin g ( fa false negative possible up to 3 months) If breakdown of p oss ossii bl bl e u p t o m arg argii na na l b on on e, e, sp sp lili nt nt 3 m o n t hs ) f o r an addi tion al 3-4 weeks • M a r g i n a l bone • External height c or or rree sp sp on on ds ds to to i nf nf la la mm mm at at or or y rroo ot ot resorption or that seen replacement resorption radiographically • Endodontic therapy after r e p o s it io n i n g ap pr pro p ria te f oorr • C on on titi nu nu in in g r oooo t s ta tag e o f r oooo t d ev ev el elo pm pm en en t in d ev ev el elo pm pm en en t is im m maa tu tu rree t ee eeth i nd nd ic ic at ate d • T o o th in place • Tooth locked in o r e r u p t i ng p la ce/ankyloti c tone • I n ta c t l am i na to percussion • Radiographic signs dura • No sig n s o f o f apical r e s o r p t io n p e r io d o n t it i s • Continuing root • External inflammatory root development in resorption or i m m a t u r e t ee th replacement resorption • Endodontic therapy appropriate appropri ate fo r stage of root development is indicated
necrotic in teeth with complete root formation. Root canal therapy using a temporary filling with calcium hydroxide is recommended and treatment should begin 2-3 weeks after surgery Once an intruded tooth has been repositioned surgically or orthodontical orthodontically, ly, stabilize with a flexible splint for 4-8 weeks C44, clinical and radiographic examination; S4, splint removal; S44, splint removal in cervical third fractures. 1For crown-fractured teeth with concomitant luxation injury, use the luxation follow-up schedule. 2Whenever there is evidence of external inflammatory root resorption, root canal therapy should be initiated immediately, with the use of calcium hydroxide as an intra-canal medication.
Copyright © 2012 2012,, International Association of Dental Traumatology, www.iadt-dentaltrauma.org. Reprinted with permission of the In ternational Associatio Association n o f Dental Traumatology (IAD (IADT) T).. Denta l Tra umatolo gy 2012;28 2012;28:2-12; :2-12; d oi: I0.1ll1/j.l600-9657.20l1.0 I0.1ll1/j.l600-9657.20l1.01103.x. 1103.x. Available at http://onlinelibrary.wiley.eom/doi/W.lW/j.1600-9657.20n.01W3.x/full. 330
ENDORSEMENTS
AMER ICAN
Patient instructions
Patient compliance with follow-up visits and home care contributes to better healing following a TDI. Both patients and parents of young patients should be advised regarding care of the injured tooth/teeth for optimal healing, prevention of further injury by avoid ance of participation in contact sports, meticulous oral hygiene, and rinsing with an antibacterial such as chlorhexidine gluconate 0.1% alcohol free for 1-2 weeks. Ad di ti o nal res ou rc es
Besides the general recommendations mentioned earlier, clinicians are encouraged to access the DTG, the journal Dental Traumatology, and other journals for informa tion pertaining to treatment delay (37), intrusive luxations 38-47), root fractures (48-52), pulpal manage ment of fractured and luxated teeth (34, 53-64, splinting (18, 39, 65-68), and antibiotics (69).
A c k n o w le d g em en t s
IADT is grateful to the team of Dental Trauma Guide www.dentaltraumaguide.org for kindly providing www.dentaltraumaguide.org pictures to the article. References
1. color Andreasen JO,traumatic Andreasen FM, to Andersson and atlas of injuries the teeth, L. 4thTextbook edn. Oxford, UK: Wiley-Blackwell; 2007. 2. Petersson EE, Andersson L, Sorensen S. S. Traumatic oral vs non oral injuries. Swed Dent J 1997;21:55-68. 3. Glendor U. Epidemiology of traumatic dental injuries - a 12 year review of the literature. Dent Traum atol 20 2008; 08;24: 24: 603-11. 4. Flores MT. Traumatic injuries in the primary dent dentition. ition. Dent Traum atol 2002;18:2 2002;18:287-98. 87-98. 5. Kramer PF. Zcmbruski C, Ferreira SH, Fcldens CA CA.. Traumatic dental injuries in Brazilian preschool children. Dent Traumatol 2003;19:299-303. 6. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F et al. Guidelines for the management of traumati c dental injuries. injuries. 1. Fractures and luxations of perma nent teeth. Dent Traumatol 2007;23:66-71. 7. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F et al. Guidelines for the management o f traumati c dental injuri injuries. es. 11. Avulsion of permanent teeth. teeth. Dent Traumatol 2007;23:130-6. 8. Flores MT. Malmgren B. Andersson L, Andreasen JO. Bakland LK, Barnett F et al. Guidelines for the management of traumati c dental injuries. 11 111. 1. Primary Teeth. Dent Traum atol 2007;23:196-202. 9. Flores MT, Andreasen JO, Bakland LK, Feiglin B, Gutmann JL, Oikarinen K et al. Guidelines for the evaluation and management of traumati c dental injuries (part I of the series) series).. Dent Tra Trauma uma tol 2001; 17:1 :1-^ -^4. 4. 10 10.. Flores MT, Andreasen JO, B akland LK, Feiglin B B,, Gutman n JL, Oikarinen K et al. Guidelines for the eval uation and management of traumatic dental injuries (part 2 of the series). Dent Traumatol 2001;17:49-52. 11. Flores MT, Andreasen JO. Bakland LK. Feiglin B. Gutmann JL, Oikarinen K et al. Guidelines for the evaluation and management of traumatic dental injuries (part 3 of the series). Dent Traumatol 2001;17:97-102. 12 12.. Flores MT, Andreasen JO, Bakland LK, Feiglin B B,, Gutmann JL, Oikarinen K et al. Guidelines for the evaluation and management of traumatic dental injuries (part 4 of the series). Dent Traumatol 2001;17:145-8.
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Copyrigh t © 2 201 012, 2, Internationa l Association Association of Dental Traumatology, www.iadt-dentaltrauma.org. Reprinted with permission of the Inter national Association of Dental Traumatology (IAD (IADT). T). Den tal Tra Traumat umat olo ology gy 2012;28:2-12; doi: 10.11 10.1111/j.1 /j.1600-965 600-9657.2011.0 7.2011.0110 1103.x. Available at http://onlinelibrary.wiley.eom/doi http://onlinelibrary.wiley.eom/doi/l0.IIH/ /l0.IIH/j.l600-965720ll. j.l600-965720ll.0IW3.x/full 0IW3.x/full. ENDORSEMEN TS
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C o rri g e n d u m
Dent Traumatol 2012;28:49 2012;28:499 9
•
if tooth is intrud ed 3 7 mm, reposition surgically surgically or orthodontically
In DiAngelis et al. (1), the following corrections should be made:
The last word in the fourth bulleted sentence should be repositioning instead of
Unde r the heading ‘Follo ‘Follow w up’ for both lateral luxation and intrusion, the first two time periods should be read as:
surgery.
•
2 weeks, weeks, C++ (no t 2 weeks S+, C++)
•
4 weeks weeks S+ S+,, C++ (not 4 weeks C++) C++)
Reference
This makes splint removal at 4 weeks consistent with what is recommended under ‘Treatment’. Under ‘Treatment’, ‘Teeth with complete root formation’, there should be an additional second bullet to read as:
The authors would like to apologize for these errors.
1. DiAngelis AJ, Andr Andreasen easen JO, Ebeleseder KA KA et al al.. Interna tional Association of Dental Traumatology guidelines for the management of traumatic dental injuries: injur ies: 1. Fra Fractures ctures and luxations of permanent teeth. De nt Traumatol 2012; 28:212.
Copyright © 20 2012 12,, International Association of Dental Traumatology, www.iadt-dentaltrauma.org www.iadt-dentaltrauma.org.. Reprinted with permission of the International Association Association of Dental Tr aumatology (IADT) (IADT).. Den tal Tra Trauma umatolo tolo gy 2012;28:2-12; doi doi:: 10.111 10.1111/j.1 1/j.1600 600-9657.2011.0110 1103.x. 3.x. Available at http://onlinelibrary.wiley.eom/doi/10.1111/j.1600-9657.2011.0n03.x/full at http://onlinelibrary.wiley.eom/doi/10.1111/j.1600-9657.2011.0n03.x/full.. 332
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