IADT guidelines on fractures and luxations of permanent teeth (2020): flexible splints for 2 to 4 weeks, reviews out to five years, and no root canal at the emergency visit

What it says#

The guideline is a consensus statement of an International Association of Dental Traumatology working group, produced after a review of the dental literature and working-group discussion, and reviewed and approved by the IADT Board of Directors. Where the published data were not conclusive, the recommendations rest on the consensus opinion of the group. Its stated goal is an approach for the immediate or urgent care of traumatic dental injuries; this first article covers fractures and luxations of permanent teeth, and the IADT says plainly that it cannot guarantee a favorable outcome, only raise the probability of one.

Diagnosis comes first. For injured maxillary incisors the guideline recommends one parallel periapical through the midline, one aimed at each lateral incisor, one maxillary occlusal and at least one periapical of the lower incisors, on film holders so follow-up films compare; minor injuries may need fewer, and the test for any 2D or 3D image is whether it will change management, with CBCT considered for root fractures, crown-root fractures and lateral luxations. Photographs are strongly recommended. Sensibility testing is done at baseline and at every review, but no response is not conclusive for necrosis, and the tables repeat that endodontic treatment should not be started solely on that basis.

The splinting rule is one sentence: current evidence supports short-term, passive and flexible splints for luxated, avulsed and root-fractured teeth, with physiologic stabilization from stainless steel wire up to 0.4 mm in a wire-composite splint, kept away from the gingiva and proximal areas. Duration depends on the injury. From the tables: extrusive luxation, 2 weeks, plus 4 more if the marginal bone is fractured; lateral luxation, 4 weeks, plus 4 more if the marginal bone or socket wall is fractured; root fracture, 4 weeks, and up to 4 months for a cervical fracture; alveolar fracture, 4 weeks; subluxation, normally no treatment, with a splint for up to 2 weeks only if there is excessive mobility or tenderness on biting; concussion, no treatment. Intrusion depends on root maturity. An immature tooth is allowed to re-erupt without intervention regardless of the degree of intrusion, with orthodontic repositioning if nothing has happened by 8 weeks. A mature tooth intruded less than 3 mm is allowed to re-erupt, and if it has not by 8 weeks is repositioned surgically and splinted for 2 weeks (or repositioned orthodontically before ankylosis develops); at 3 to 7 mm the tooth is repositioned surgically (preferably) or orthodontically; beyond 7 mm, surgically. In a mature intruded tooth the pulp almost always becomes necrotic, so root canal treatment starts at 2 weeks or as soon as the position allows.

Crown fractures are managed to preserve the pulp. An intact fragment can be bonded back after 20 minutes of rehydration in water or saline; exposed dentin is covered with glass ionomer or bonding agent and composite, with a calcium hydroxide lining when dentin is within 0.5 mm of the pulp. For an exposure, partial pulpotomy or pulp capping is recommended in immature teeth and preferred in mature teeth too, with non-setting calcium hydroxide or a non-staining calcium silicate cement; root canal treatment is preferred in a mature tooth only when a post is needed. A displaced root-fracture segment is repositioned, checked radiographically and splinted; no endodontic treatment is started at the emergency visit, and later necrosis is usually confined to the coronal fragment, which is the only part treated. In alveolar fractures the segment is repositioned and splinted for 4 weeks, and root canal treatment is contraindicated at the emergency visit.

The endodontic section separates mature from immature teeth. In fully developed teeth that were intruded, severely extruded or laterally luxated, early endodontic treatment is typically advisable: calcium hydroxide placed 1 to 2 weeks after trauma for up to 1 month, or a corticosteroid/antibiotic paste placed immediately after repositioning and left at least 6 weeks. In immature teeth root canal treatment is avoided unless there is clinical or radiographic evidence of necrosis or periapical infection, because revascularization is possible; but infection-related resorption is very rapid in children, so reviews are mandatory and treatment starts as soon as it is seen, with calcium hydroxide placed for 3 weeks and replaced every 3 months until the resorptive radiolucencies disappear. All endodontics is done under dental dam, with the retainer on neighboring teeth.

Follow-up schedules are stated per injury (see the figure). Every review includes questioning about symptoms, clinical and radiographic examination and sensibility testing. Patients are told to avoid contact sports, keep meticulous hygiene and rinse with chlorhexidine gluconate 0.12%. On antibiotics the guideline is explicit: limited evidence in the emergency management of luxations, none that they improve outcomes in root fractures, and use at the clinician's discretion, for soft tissue injuries or the patient's medical status.

Who it applies to#

Any permanent tooth with a fracture or luxation, from an enamel crack to an alveolar segment, in a child, teenager or adult, at the visit where it is first seen. The tables cover eleven injury types. Combined injuries are called out: a crown fracture together with a luxation carries a higher risk of pulp necrosis, so the more frequent luxation schedule prevails over the fracture schedule. The guideline is written for the general dentist who takes the emergency call as much as for the specialist; the working group included the general dentistry community.

It does not reach avulsions (part 2, with its own entry here) or primary teeth (part 3). It also stops at the unfavorable outcome: where ankylosis, resorption or infection is identified, treatment is often required and the tables say that is outside the scope of the guidelines, with referral advised.

What changed#

The 2020 guidelines are the IADT's fourth set; the general introduction records the first in 2001, an update in 2007 and a further update in 2012, and the avulsion article describes the 2020 texts as a revision and update of the 2012 guidelines. This entry did not compare the 2012 and 2020 tables line by line. What the 2020 text itself presents as current: the core outcome set for dental trauma published in 2018, which the tables use to define favorable and unfavorable outcomes; CBCT as a consideration for root, crown-root and lateral luxation injuries; a preference for conservative pulp therapy in mature as well as immature teeth; and the explicit 3 mm and 7 mm thresholds for intruded mature teeth.

Where the source is#

The document is Bourguignon and colleagues, International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations, Dental Traumatology 2020, volume 36, issue 4, pages 314 to 330, published for the IADT by Wiley under a CC BY-NC-ND license; the link under the title is the DOI. When this entry was written Wiley's site refused automated access (HTTP 403 to both a browser fetch and curl), so the text was read from two open copies: the AAPD's reprint of the published article, made with Wiley's permission in the Reference Manual of Pediatric Dentistry (pages 600 to 615), and, because the treatment tables are images in that reprint, the accepted author manuscript deposited at White Rose Research Online by the University of Leeds, which carries Tables 1 to 13 as text. The accepted manuscript may differ in small ways from the version of record. The abstract was also read on PubMed (PMID 32475015). The IADT's own site links all four 2020 parts and the free ToothSOS app.