The American Association of Endodontists outlined treatment recommendations based on root maturity, intrusion severity, extraoral dry time, and risk of pulp necrosis or ankylosis.

The American Association of Endodontists (AAE) guidelines, revised in September 2013, address tooth fractures, alveolar fractures, concussion, subluxation, luxation, and avulsion injuries in permanent dentition. While the recommendations are intended to aid clinicians, the AAE stated that they aren't fixed protocols, with treatment decisions shaped by patients’ health, teeth, physical condition, and personal preferences.

For crown fractures without pulp exposure, the AAE recommends bonding an available tooth fragment to the tooth or covering exposed dentin with glass ionomer or bonded composite resin. For fractures with pulp exposure, the guidelines suggest preserving pulp vitality with pulp capping or partial pulpotomy in teeth with open apices, and state this approach may also be the preferred treatment among patients with closed apices. Calcium hydroxide compounds and white mineral trioxide aggregate are listed as suitable materials.

For root fractures, the guideline recommends rinsing exposed root surfaces with saline, repositioning displaced coronal segments as soon as possible, confirming position radiographically, and administer a flexible splint for stabilization of the tooth for a period of 4 weeks. Cervical root fractures may benefit from stabilization for up to 4 months. The AAE recommends monitoring healing for at least 1 year to determine pulpal status, with root canal treatment indicated in the case of pulp necrosis.

The guideline distinguishes concussion, subluxation, and luxation injuries by percussion tenderness, mobility, and displacement. Concussion generally requires no immediate treatment, whereas subluxation may require a flexible splint for 2 weeks. Extrusive and lateral luxation require saline irrigation, repositioning, suturing of gingival lacerations when present, and flexible splinting for 2 weeks to 4 weeks, depending on the extent of the displacement.

For intrusive luxation, treatment depends on intrusion depth and root development. Teeth with incomplete root formation and up to 7 mm of intrusion may be allowed to re-erupt without intervention, with orthodontic repositioning initiated within 3 weeks if no movement occurs. Teeth with complete root formation and intrusion between 3 and 7 mm should be repositioned surgically or orthodontically within 3 weeks, while intrusion greater than 7 mm should be managed surgically followed by 2 to 4 weeks of flexible splinting.

The AAE states that pulp necrosis following trauma should be diagnosed by at least two signs or symptoms. In patients with mature apices who are noncompliant or have limited access to care, lack of response to pulp sensibility testing by 3 months is strongly indicative of pulp necrosis.

Cone-beam computed tomography may be considered in selected injuries to clarify fracture direction, confirm tooth repositioning, or evaluate alveolar bone fractures. The guideline recommends conventional radiographs routinely and suggests cone-beam computed tomography selectively in some injuries.

For avulsed mature permanent teeth with closed apices, management depends on whether the tooth has already been replanted, stored in a physiologic or osmolality-balanced medium, stored dry for up to 60 minutes, or kept dry for more than 60 minutes. For teeth stored in Hank’s balanced salt solution, saline, or milk, or stored dry for up to 60 minutes, the AAE recommends handling the tooth by the crown, cleaning the root surface and apical foramen with saline, administering local anesthesia, irrigating the socket with saline, replanting with slight digital pressure, suturing gingival lacerations, verifying the position radiographically, and applying a flexible splint for 1 to 2 weeks. Root canal treatment should begin 7 to 10 days following replantation and prior to splint removal if not performed immediately.

For avulsed permanent teeth with open apices, the goal of replantation is possible revascularization of the pulp space. The guideline recommends avoiding root canal treatment in very immature teeth unless clinical or radiographic evidence of pulp necrosis is present. If delayed replantation occurs following more than 60 minutes of extraoral dry time, the guideline states that long-term prognosis is poor and that ankylosis and root resorption are expected outcomes.

Systemic antibiotics are recommended following avulsion: amoxicillin for 7 days in patients younger than 12 years and doxycycline for 7 days in patients older than 12 years, with dosing based on age and weight. If the avulsed tooth contacted soil and tetanus coverage is uncertain, the guideline recommends referral to a physician for a tetanus booster.

Follow-up ranges from splint removal at 2 to 4 weeks, depending on injury type, to clinical and radiographic examinations at 2 weeks, 4 weeks, 3 months, 6 months, 1 year, and yearly thereafter for up to 5 years in avulsion cases. In pediatric and adolescent patients at risk for ankylosis-associated infraposition, growth monitoring with weight and height measurements may help determine timing of decoronation if needed.

“Variations in an individual patient’s health, teeth, physical condition, and personal preferences are important factors in an endodontist’s treatment recommendation,” the AAE concluded.

The guideline acknowledged cooperation with the International Association of Dental Traumatology. No author conflict-of-interest disclosures were included in the document.

Source: AAE