PaediatricDentistry/Orthodontics

Helen D Rodd

Alison M Murray, Grainne Yesudian and Benjamin RK Lewis

Decision-making for Children with

Traumatized Permanent Incisors: A
Holistic Approach
Abstract: Traumatic injury to permanent central incisors is a common occurrence in childhood and adolescence. It is of paramount
importance that expedient and appropriate care is provided to ensure an optimum short- and long-term outcome for injured teeth and,
importantly, the patients themselves. Treatment planning should thus adopt a holistic approach, taking into account a number of patient-
and dental-related factors. Multidisciplinary care, involving paediatric dentistry, orthodontics or oral and maxillofacial surgery may be
indicated. Decisions should also be informed by a sound understanding of the exact nature and prognosis of the presenting dental injury.
Clinical Relevance: Poor primary management of dental trauma may have lifelong consequences for the young patient.
Dent Update 2008; 35: 439-452

Management of dento-alveolar trauma
in young patients is a demanding area
of dental care provision. Emergency care
poses additional challenges, as children
are often distressed, have little previous
experience of dental treatment and
have to be accommodated within a busy
clinic schedule. However, it is critical that
immediate and appropriate primary
Helen D Rodd, BDS, FDS RCS(Paed),
PhD, Professor and Honorary Consultant
in Paediatric Dentistry, Department of
Oral Health and Development, School
of Dentistry, University of Sheffield,
Alison M Murray, BDS, FDS RCS, MSc,
MOrth, Consultant Orthodontist,
Derbyshire Royal Infirmary, Grainne
Yesudian, BDS, Trust Grade in Paediatric
Dentistry, Department of Oral Health
and Development, School of Dentistry,
University of Sheffield and Benjamin RK
Lewis, BDS, MFDS RCS, MClinDent, MOrth,
Specialist Registrar, Derbyshire Royal
Infirmary, Derbyshire, UK.
September 2008
management is initiated in order to
ensure the best possible prognosis for the
traumatized tooth and the most positive
experience for the child. However, it would
seem that management of dental trauma in
the primary care setting is, regrettably, often
far from optimal.
Recent epidemiological data
from the 2003 Dental Health Survey of
children in the UK identified that only 27%
of visibly damaged permanent incisors
in 15-year-olds were treated.1 Equally
concerning was the report that 38% of
complicated crown fracture s in children
referred to a British dental hospital had
not received emergency pulp coverage
from the referring primary dental carer.2
An evaluation of root-treated permanent
incisor teeth in children in the North West
of England found 92% to be unsatisfactory.3
Barriers to adequate treatment provision
may include poor access to services,
inadequate remuneration, time constraints,
and lack of clinical experience. A number
of postal surveys of British dental
practitioners have revealed an inadequate
level of knowledge with respect to trauma
management.4,5 In light of these findings,
dental traumatology warrants greater
emphasis within both the undergraduate
dental curriculum and continuing
postgraduate education.
The overall aim of this paper is
to highlight the need for a holistic approach
to trauma management, particularly with
respect to the orthodontic/paediatric
dentistry interface. Good decision-making
should take into account the whole
patient and not just the traumatized
tooth. Treatment decisions should also be
informed by a sound knowledge of the
specific dental injury and likely prognosis.
It is not possible within the constraints of
this single paper to provide a prescriptive
account of how every different dental injury
should be managed. However, Table 1 lists
key evidence-based clinical guidelines for
further reference.
Trauma prevalence
Dental injury during childhood
and adolescence is common. The 2003
Child Dental Health survey reported that
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injury, others are unfortunate enough to

Guideline
Management and root
canal treatment of non-
vital immature
permanent incisor teeth
Treatment of avulsed
permanent incisor teeth
in children
Treatment of traumatically British Society of Paediatric
intruded permanent Dentistry
incisor teeth in children
Management of acute
dental trauma
Guidelines for the
evaluation and
management of traumatic
dental injuries
Table 1. Clinical guidelines.
Professional Organization
British Society of Paediatric
Dentistry
British Society of Paediatric
Dentistry
American Academy of Pediatric
Dentistry
International Association of
Dental Traumatology
Reference
Mackie IC. International
Journal of Paediatric
Dentistry 1998; 8:
289293.
Gregg TA, Boyd D.
International Journal
of Paediatric Dentistry
1998; 8: 7581. with reported high levels of paternal
Kinirons MJ.
International Journal of
Paediatric Dentistry
1998; 8: 165168. of incisor trauma to be 24%, with children
Pediatric Dentistry
2004; 26: 120127.
Flores MT et al. Dental
Traumatology 2001; 17:
97102, 145148,
193198.
suffer from multiple incidents throughout
their childhood and youth.11,12
Adverse psychosocial environments
There appears to be an
association between life course experiences
and the occurrence of traumatic dental
injuries in adolescents. It has been shown
that children from non-nuclear families,
punishment and low school grades, are at
the greatest risk of dental injury.13 A study
of 14-year-old schoolchildren in a deprived
area of London found the overall prevalence
from overcrowded households significantly
more at risk of dental injury.14
Sports participation
Second to accidental falls,
sports-related activities are usually the next
most common cause of dental trauma.15
Each year, approximately 24% of children
who participate in contact sports sustain
dental injuries.7

11% of 12-year-olds and 13% of 15-year-
olds had visible evidence of trauma to their
permanent incisors.1 However, data from
cross-sectional surveys, such as this, may in
fact underestimate the true prevalence of
dental injury. A prospective study of Danish
children found that almost 50% of all
school leavers had experienced at least one
episode of dental trauma.6 Crown fractures
are by far the most common injury seen in
children.7
The child at risk of dental trauma
It is important to recognize that
some children are at greater risk of dental
trauma than others in order that targeted
education and preventive interventions
can be initiated. Gender differences have
been well described, with boys being
approximately twice more at risk of
sustaining dental trauma than girls.7 Age is
also a relevant factor, with the peak age for
injury to permanent incisors being between
8 and 10 years.7 However, more detailed
surveys have revealed a number of specific
risk factors for childhood dental trauma,
which are described as follows.
Increased overjet and incomplete lip
coverage;
Previous dental trauma;
Adverse psychosocial environments;
Sports participation;
Medical status.
Increased overjet and incomplete lip coverage
It has been well established
that an increased overjet, particularly
where there is inadequate lip coverage, is a
significant predisposing factor for maxillary
incisor trauma.8,9
Previous dental trauma
A Danish study has given
considerable insight into the risk of multiple
dental trauma episodes in certain children
and adolescents.10 The investigators found
that the risk of sustaining another trauma
episode increased by 1530% when the
first trauma occurred before the age of 11,
compared to a risk of repeat injury of 07%
when the first injury was sustained after
the age of 10. Numerous other studies have
also established that, whilst some children
only ever experience one episode of dental
Medical status
Some underlying medical
conditions, particularly those manifesting
with poor motor control, may predispose
children to dental trauma. A study of
children with cerebral palsy found visible
signs of permanent incisor trauma in 57% of
the participants.16 A significant association
between incisor fracture and attention-
deficit/hyperactivity disorder has also been
recently demonstrated and may relate to
the accident-proneness of these children.17
Clinical obesity appears to be a further risk
factor in dental trauma.18
For those children identified
as being trauma-risk, strategies should
be implemented to limit the risk of future
injury. These may include early orthodontic
intervention, in the mixed dentition, to
reduce overjet.19 It is interesting to note,
however, that no studies appear to have
been undertaken to prove the effectiveness
of overjet reduction in reducing trauma risk.
However, as it has been shown that children
with an overjet of greater than 6 mm are
approximately three more times likely to
sustain incisor trauma than those with an
overjet of 3.5 mm or less, there is indirect

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a b
Figure 1. Acute presentation of a 15-year-old boy with a severely extruded upper right central incisor: (a) before treatment and (b) after repositioning and
splinting with composite and wire and placement of sutures to gingival lacerations. (c) Additional injuries comprised an enamel fracture of the lower left central
incisor and an enamel/dentine fracture of the lower right central incisor (temporarily restored with a composite bandage).
b
Figure 2. Acute presentation of a 14-year-old
girl with uncomplicated enamel/dentine crown
fractures of both upper central incisors: (a) before
treatment and (b) after reattachment of crown
fragments.
evidence to support early orthodontic
intervention.8 It is also important to
consider the provision of a custom-made
mouthguard for contact sports and other
recreational activities.20
History and examination
A thorough history, clinical and
radiographic examination is paramount to
good treatment planning. The possibility
of cerebral trauma should also be assessed,
and for avulsion injuries it is essential to
elicit the exact time period that the tooth
has been allowed to remain dry as this is
the most important prognostic factor for
442 DentalUpdate
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c
tooth survival, as will be discussed later.
Care must also be taken to identify all
dental injuries as attention may be focused
on the main presenting injury and other,
lesser, injuries may be missed (Figure 1).
Thorough documentation,
which may be supplemented by annotated
diagrams and clinical photos, is mandatory.
Intra-oral radiographs are frequently
required for luxation injuries and suspected
root fractures. In addition to showing the
actual injury or pathology, radiographs
indicate the degree of apical development,
which largely informs treatment options,
prediction of overall prognosis, and future
monitoring of the vitality of teeth. Special
investigations such as sensitivity testing,
percussion, and transillumination may also
be indicated.
The history and examination
process also allows the clinician the
opportunity to develop some rapport
with the young patient and to gain an
impression of the likely co-operation of the
patient for subsequent treatment.
Primary treatment provision
Following an acute presentation
of dental trauma, it is essential that both
expedient and appropriate primary care are
provided. Poor emergency management
and decision-making may subject the child
to unduly prolonged courses of treatment,
which may still ultimately result in the loss
of a tooth and its supporting tissues. Delay
in primary treatment provision may also
adversely affect tooth prognosis.
A review by Andreasen and
colleagues provides a comprehensive
analysis of the relationship between
treatment delay and complications in
pulpal and periodontal healing for the
full spectrum of dental injuries.21 An
uncomplicated (enamel-dentine) crown
fracture should ideally be treated within 24
hours. A significant relationship between
pulp necrosis and a 3-day delay in dentinal
coverage was identified. In addition to
pulpal complications, delayed treatment
provision may also allow movement of
opposing or adjacent teeth such that
there is inadequate space to restore the
fractured incisor to its normal dimensions
subsequently.
Treatment delay for fractured
incisors with pulp exposures is considered
detrimental to pulp survival. In addition,
the patient may be experiencing
considerable sensitivity to thermal and
mechanical stimuli. The key objective
in this instance is to provide a hermetic
seal over the exposed pulp to minimize
bacterial invasion. The removal of
suspected infected pulpal tissue should
be carried by pulpotomy, for an immature
tooth, or pulpectomy, if root development
is complete.2,22 Direct pulp capping using
calcium hydroxide is likely to be most
successful if undertaken within 24 hours
of pulpal exposure.23 Definitive composite
restorations may not be possible at the
initial presentation. However, a lining and
composite bandage should be placed
over the exposed dentine, until further
treatment can be carried out. Glass
ionomer cements are not considered to
perform as well as composite materials in
this situation. Reattachment of fractured
incisor fragments, in conjunction with
some tooth preparation, may also provide
a valuable restorative approach (Figure 2).24
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a b c

d e f

g h

objectives.
It should also be borne in
mind that treatment planning is a flexible,
iterative process and may need to be
revised with new presentations such as
repeat trauma, pathological sequelae or
deterioration in patient compliance.

i j Patient and family preferences

The demands placed
on a patient and his/her carers to
undertake comprehensive treatment
following dental trauma should not be
underestimated. Patient-borne costs,
such as travel expenses and loss of
earnings for accompanying adults, may
be considerable, and there may be an
impact on the young persons schooling,
Figure 3. A series of photographs to demonstrate good aesthetic results for young patients following
social activities and other siblings.25
dento-alveolar trauma. (a-c) A 13-year-old boy with traumatic loss of the upper left lateral incisor with
provision of a partial denture to restore aesthetics and maintain space until future implant provision.
Young patients attending a London dental
(d-f) A 14-year-old girl with fractured and non-vital upper right central incisor, which was treated hospital following dental trauma were
endodontically, subject to internal bleaching and restored with a direct composite restoration. (g-j) A found to require a mean of 10.4 visits
15-year-old boy with traumatic loss of the upper right lateral incisor with has been replaced with an (range 327) for a course of treatment
adhesive bridge. and 25% lived more than 10 miles away
from the hospital.15 Treatment involving
repeated calcium hydroxide placement
to achieve apical closure in an immature,
Decision-making centred and carer preferences; non-vital incisor usually results in the
A variety of factors should be Significant medical history; greatest number of visits.26 It is, therefore,
taken into consideration when deciding Past dental history; important that, from the outset, the
on the best possible course of treatment Compliance; clinician explains to the child and family
for children following dental injury. Every Orthodontic considerations; the demands that will be placed on them
trauma intervention should be tailored to A sound understanding of the likely according to which treatment option is
the individual and should take into account outcomes and prognosis of the dental pursued. Evidence-based information
the following: injury; and should also be given as to the likely
Psychosocial factors, including child- An appreciation of long-term treatment outcomes of the injury so that children

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and their carers can reach an informed
decision about what is best for them as a
family.
Psychosocial impact
Appearance, particularly
facial appearance, is central to social
experience and interaction throughout life.
Interestingly, untreated dental trauma has
been shown to have a negative impact on
a childs psychosocial status.27 Furthermore,
dissatisfaction with dental appearance
has been identified as the main reason for
young people to seek treatment following
incisor trauma.3 Practitioners should,
therefore, strive to achieve the best possible
aesthetic solutions for children during such
a critical stage of their social development
(Figure 3).
Medical status
Children at risk of infective
endocarditis or who are severely immuno-
compromised require careful management
following dental trauma and may require
referral to a paediatric dentistry specialist
for continued care. For children with severe
learning difficulties, interventions such as
tooth replantation may be contra-indicated
if it is not going to be possible to carry out
subsequent treatment in the dental chair.
Repeated reliance on general anaesthesia
for ongoing trauma management is not
justified in view of the associated risks.
Orthodontic considerations
There may be a number of
orthodontic considerations for the young
patient who sustains incisor trauma.
Orthodontic intervention, such as tooth
extrusion, may be required as part of
primary or secondary trauma management.
Additionally, orthodontic patients may
have a past history of incisor trauma or may
sustain trauma during active treatment. It
is thus essential that good communication
be maintained between the general dental
practitioner and orthodontist when sharing
the care of patients with incisor trauma. The
orthodontist is ideally placed for regular
clinical and radiographic review of the
injured tooth and should inform the general
dental practitioner should any intervention
be required for the management of trauma
sequelae, such as loss of vitality.
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Orthodontic treatment and previously
traumatized teeth
Not surprisingly, a number
of children who have a history of dental
trauma subsequently embark on a course
of orthodontic treatment.19 Although past
dental injury is not a contra-indication for
orthodontic tooth movement, patients
and clinicians should be aware that
there is an increased risk of apical root
resorption in previously traumatized teeth.28
However, there is conflicting evidence as
to whether endodontically treated teeth
show a reduced or increased propensity
for root resorption following orthodontic
treatment.29 Notwithstanding, it is essential
that any endodontic treatment undertaken
prior to orthodontics should be of the
highest clinical standard.30
For all patients with a past
history of trauma, it is prudent to monitor
the incisor roots during orthodontic
treatment radiographically by taking
baseline views and repeating them
approximately six months into treatment.
If excessive root resorption is seen, then
active treatment should cease for a three-
month period.31 This should allow time for
replacement of some of the cementum.
On recommencement of active treatment,
more frequent monitoring is advised. If the
resorption is very severe, or continues, a
compromised treatment plan may need to
be considered.
Following commencement
of orthodontic treatment, previously
traumatized teeth should also be monitored
for signs of pulpal deterioration. Assessment
of the clinical appearance, response to
vitality testing, percussion of the tooth and
reported sensitivity to hot and cold can
easily be made on a three-monthly basis
and any changes should be noted and
acted upon. A radiograph may demonstrate
early pathological change such as a
periapical lesion or root resorption.
Orthodontic treatment and teeth traumatized
during treatment
If a patient sustains dental
trauma whilst undergoing orthodontic
treatment, some protection may be
afforded by the stabilizing effect of the
appliance itself. Thus the injuries are more
likely to be of a minor nature. In cases
of relatively minor trauma, where teeth
are not displaced, a period of appliance
deactivation is recommended.31 This is
usually in the order of three months to
allow tissue healing to occur. Following
more severe trauma, teeth tend to be
laterally or vertically displaced, rather than
avulsed, as they are held in situ by the fixed
appliance. Realignment of these teeth is
recommended using a light flexible wire
and, once alignment is achieved, a passive
splinting phase is recommended.31
If loss of pulpal vitality occurs
during active treatment, it is currently
recommended that non-setting calcium
hydroxide paste be placed in the root canal
and a conventional root filling carried out
once treatment is complete.29,31 However,
increasing evidence that calcium hydroxide
root canal dressings significantly reduce
the fracture resistance of teeth means
that this recommendation may need to be
reviewed.32
Ankylosis
Intrusion or avulsion injuries
carry a high risk of replacement root
resorption and dento-alveolar ankylosis due
to irreversible damage to the periodontal
ligament. This may result in considerable
disruption to vertical alveolar development
in the growing patient. Occurrence before
the age of ten, or before the pubertal
growth spurt, has been shown to be
associated with a particularly high risk of
severe tooth infraposition.33 Early diagnosis
and intervention is thus imperative. A
variety of treatment approaches may be
considered, according to the growth status
of the child, and may include the following
options.
1. Autotransplantation
If incisor ankylosis is diagnosed
early, premolar transplantation may be
considered. Long-term studies have
reported excellent outcomes, with an 82%
survival rate after 7 years.34 The approach
is particularly suitable for patients with
premolar crowding, although it should
be considered even in patients with little
or no crowding because of the relative
ease of space closure in the upper arch.
The advantage of the technique is that
bone will continue to develop around
the transplanted premolar and the tooth
can be modified to simulate an incisor.
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a b Thus the symmetry of the labial segment

is maintained (Figure 4). Orthodontic
treatment may be commenced shortly
after transplantation (36 months) without
an increased risk of failure. However, if the
tooth is subsequently lost, provided that
alveolar bone has developed as would be
expected, replacement of the tooth with an
implant, at the appropriate age, would be a
c d possibility.

2. Alveolar distraction/single tooth osteotomy

In patients where ankylosis
has been noted too late to consider
autotransplantation and a vertical bony
deficiency has occurred, a local osteotomy
may be considered. Once the vertical height
of the bone has been lengthened to restore
Figure 4. Series of photographs to show premolar autotransplantation to replace the lost upper left
normal anatomy, replacement of the teeth
central incisor: (a) orthodontic alignment to create space for transplant; (b) surgical creation of socket
can be carried out (Figure 5).
and transplantation of premolar ensuring integrity of periodontal ligament; (c) second premolar in upper
left incisor position; (d) premolar crown modified with direct composite restoration to resemble an
incisor. Definitive orthodontic treatment is delayed until sufficient eruption of all permanent teeth. Forced tooth eruption
In cases where a subgingival
a b crown fracture has occurred, restorative
treatment may be facilitated by orthodontic
tooth extrusion (forced eruption) to
increase the crown height and allow
a supragingival restorative margin. 35
Orthodontic intervention may also be
indicated in the primary management of
an intruded permanent incisor with mature
apical development (Figure 6). 36
c d
Prognostic factors according to tooth injury
type
The clinician should have a
thorough knowledge of the likely trauma-
related outcomes associated with the
specific injury, so that informed treatment
decisions are made together with the
patient and the carer. Individual values may
differ widely in this respect, as some people
may still choose to embark on lengthy and
demanding courses of treatment even
when tooth loss is inevitable. The overall
prognosis and complications of some of the
more severe dental injuries are discussed
Figure 5. Orthodontic treatment in conjunction with alveolar distraction in a 15-year-old boy: (a)
below.
18-months following dental injury, with loss of the upper right central incisor, severe intrusion of the
upper right canine and repositioned upper left central incisor: the canine was extracted and orthodontic
treatment commenced. However, ankylosis of the anterior teeth prevented any attempt to extrude Avulsions
the teeth orthodontically. (b) Therefore, a small distractor was placed under general anaesthetic to The decision whether or not
the anterior alveolus to allow extrusion of the anterior maxilla. As the teeth came into occlusion, the to replant an avulsed permanent incisor
incisal edges were removed to allow as much bony development as deemed necessary to achieve
is probably the most difficult and emotive
more aesthetic gingival margins. (c) Lateral cephalometric radiograph with the distractor in situ before
one in trauma management. However, there
extension. (d) Lateral cephalometric radiograph with the distractor in situ after extension.
is now a wealth of evidence to support
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a b
Figure 6. (a) Acute presentation of a 14-year-old boy with severe intrusion of the upper left central incisor and loss of the lateral incisor. (b, c) Provision of a
removable appliance to extrude the upper left central rapidly and to replace the missing lateral incisor with a prosthetic tooth.
a b
Figure 7. Presentation of an 8-year-old boy two
weeks following replantation of both upper
central incisors. The upper central incisors had an
extremely poor prognosis with lack of supporting
tissue, and were subsequently extracted. In view
of the moderate degree of labial crowding, the
upper lateral incisors were allowed to erupt into
the position of the central incisors in the short
term, which helped to maintain alveolar bone in
this region.
the extremely poor outcome of tooth
replantation (Figure 7). Unless the tooth is
replanted immediately (within five minutes),
there is little chance of regeneration of
a functional periodontal ligament and
replacement resorption, ankylosis and tooth
loss will ensue.37,38 However, expedient
removal of necrotic pulp and appropriate
endodontic therapy will help to reduce the
compounding problem of inflammatory
root resorption (Figure 8).38
Nevertheless, even with a
bleak long-term outlook, replantation
and endodontic treatment may still be
the preferred option for some adolescent
patients (although the potential
complication of ankylosis and infraocclusion
in a younger patient must be taken into
consideration). A replanted tooth that
remains an aesthetic, symptom-free and
functional space maintainer for a number of
years may still be considered an acceptable
outcome.
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PaediatricDentistry/Orthodontics
c
Figure 8. Intra-oral radiographs of avulsed and replanted upper central incisors showing pathological
sequelae two years following initial treatment. (a) Periapical pathology of the upper right central incisor
associated with poor endodontic treatment and external resorption (arrow) of the upper left central
incisor. (b) 12-months following placement of non-setting calcium hydroxide in the root canals the
resorption of the upper left central incisor appears stable, but there is evidence of active cervical root
resorption (arrow) of the right central incisor.
Intrusions development to prevent the development
Intrusion injuries also tend of inflammatory root resorption.38
to carry a bleak outlook, which is largely
dependent on the degree of intrusion.
Studies have shown that, whereas intrusions Lateral luxations
of less than 3 mm have an excellent A lateral luxation injury may
prognosis, those with an intrusion of more also result in irreversible damage to the
than 6 mm will ultimately be lost owing periodontal ligament cells and pulpal
to progressive inflammatory resorption neurovascular supply. A Canadian study
following overwhelming injury of the found a prevalence of 40% for both pulpal
periodontal ligament cells.39 An additional necrosis and pulp canal obliteration in a
complication of moderate to severe sample of luxated incisors in adolescents.40
intrusion is damage to apical vascular The same study reported that pulpal
and neural structures with resultant pulp necrosis was diagnosed within the first 12
necrosis. Thus pulp extirpation should months in the vast majority of cases, but no
be initiated as soon as possible after teeth were lost during the four-year follow-
intrusion of incisors with complete root up period.
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a b

Figure 10. Evidence of bone atrophy, particularly

of the labial alveolus, following loss of the upper
right central incisor in an 11-year-old boy.

Endodontically treated teeth

Regrettably, cervical root
Figure 9.(a) Horizontal root fracture at the gingival margin of the upper right central incisor in a 12-year- fracture is a common late complication
old boy. (b) The root was obturated with gutta percha and retained under a partial denture to help in teeth that have undergone, or are
maintain the alveolar bone until future implant placement. undergoing, endodontic treatment
(Figure 9). It has been reported that
a b between 28% and 77% of luxated non-
vital incisors incurred a horizontal crown/
root fracture during a four-year follow-up
period.41 Laboratory studies have also
shown that prolonged use of calcium
hydroxide root dressings, to stimulate
apexification, may substantially weaken
immature teeth.32,42 The emerging

c e

g
d

Figure 11. Orthodontic management of a 14-year-old girl with a previously avulsed and replanted upper left central incisor: (a) intra-oral radiograph two-years
after incisor replantation showing ongoing root resorption despite placement of calcium hydroxide in root canal; (b) intra-oral radiograph showing a cervical
crown/root fracture of the upper left central incisor following repeat trauma; (c) temporary direct composite and wire splint; (d) following root removal, fixed
orthodontic therapy was undertaken to correct the Class II division 2 incisor relationship and a prosthetic tooth was carried on the fixed appliance to maintain
aesthetics and space; (e) subsequent placement of an implant to restore the upper left central incisor; (f) lateral cephalometric radiograph demonstrating good
implant angulation; (g) completed treatment.

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use of mineral trioxide aggregate, as
an alternative to calcium hydroxide
root therapy, may be associated with
better outcomes, as well as having the
advantage of a much reduced treatment
time, usually a single visit, for non-vital
immature incisors.43,44
Long-term treatment objectives
Treatment planning for
children with dental trauma should
include long-term objectives to ensure
that future options are not compromised
by poor decisions made at an earlier
stage. For example, root retention in
teeth that have suffered a cervical
crown/root fracture may help maintain
alveolar bone for future restorative
options (Figure 9).45 Alveolar bone
resorption is an inevitable consequence
of tooth removal and, in children,
may amount to a 25% reduction in
supporting tissue over a six-month
period following loss of a permanent
incisor (Figure 10).46 An insufficiency of
alveolar bone may then compromise
future treatment options since the
success of implants or mucosal-borne
dentures is dependent on an adequate
bone mass (Figure 11). Preservation of
alveolar bone is thus one of the key aims
in the management of young patients
with traumatized teeth.
Trauma review
Finally, frequent review
following dental trauma is mandatory.
Close clinical and radiographic
monitoring will ensure that any loss
of vitality, pathological changes, or
disturbed development are diagnosed
promptly and appropriate treatment is
provided at the earliest opportunity.
Summary
Young patients who have
sustained trauma to their permanent
incisors are likely to be seen by both
general dental practitioners and
orthodontists. It is important that
treatment provision is evidence-based
and holistic to ensure that the best
possible dental and personal outcomes
are achieved.
September 2008
pg439-452 Decision making for children.indd 13
PaediatricDentistry/Orthodontics
Acknowledgements
Thanks are given to Peter
Day and Gerry Rahilly for providing the
clinical photographs depicted in Figure 4.
Recognition is also given to Annie Morgan
and Rakhee Malhotra for carrying out
the treatment shown in Figures 1 and 2,
respectively.
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Peter Carrotte
Glasgow Dental School
September 2008
10/9/08 15:00:31