International Association of Dental Traumatology Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent Teeth

Board takeaway

• Identify: Diagnose the crown/root injury and any accompanying luxation or alveolar injury.
• Plan: The combination, root maturity, and displacement determine repositioning, splinting, pulp treatment, and recall.
• Interpret tests: A single negative sensibility test soon after trauma does not prove necrosis.
• Pulp: Preserve viable pulp where appropriate, particularly in immature permanent teeth.
• Distinguish pathways: Mature intrusion and lateral luxation have different early endodontic pathways from root fracture or an open-apex injury.
• Timing: State the exact injury before giving a splint duration or an endodontic deadline; the IADT recommendations combine evidence with expert consensus.

Decision map: intrusion in a permanent tooth

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This map covers permanent-tooth intrusion only. Preserve the depth-specific plan, splinting where applicable, early mature-tooth endodontics, and injury-specific recall schedule below. In immature teeth a negative sensibility test alone does not establish necrosis; combined crown injury can justify considering earlier treatment.

Identify all injuries and select imaging

• Examine teeth, occlusion, alveolar bone, and soft tissues; document findings, treatment options, prognosis, and baseline pulp responses.
• Account for missing fragments. With a missing fragment and soft tissue injury, image the lip/cheek for embedded tooth material or debris.
• Combined crown fracture and luxation increases pulp necrosis/infection risk; use the more frequent luxation follow-up schedule.
• Obtain justified, reproducible baseline radiographs with holders. One view may miss root or bone fractures.
• Example anterior series: midline maxillary periapical, right/left lateral-incisor periapicals, maxillary occlusal, and mandibular central-incisor periapical. Adapt to the injury; minor infractions need less imaging.
• Root/crown-root fractures and displacement injuries generally require additional angulations and an occlusal view. Consider CBCT for fracture location/extent or lateral luxation when it could change management.
• Photograph initially and during follow-up: soft tissue healing, discoloration, re-eruption, and ankylosis-related infra-position.

Crown fractures

Enamel infraction

• Crack without tissue loss.
• Usually no treatment; severe infractions may be etched/sealed to reduce bacterial contamination and discoloration.
• No scheduled review if confidently isolated; associated injury determines recall.

Enamel fracture

• Reattach available fragment, smooth edges, or restore with composite according to extent/location.
• Review at 6–8 weeks and 1 year.

Enamel-dentin fracture without exposure

• Seal dentin with glass ionomer or bonding/composite.
• Rehydrate an intact fragment in water/saline for 20 minutes before bonding.
• If remaining dentin is within 0.5 mm of pulp, appearing pink without bleeding, use a calcium hydroxide lining covered by glass ionomer.
• Review at 6–8 weeks and 1 year.

Complicated crown fracture

• Favor conservative vital pulp treatment, particularly partial pulpotomy; pulp capping is another source option.
• This applies to mature teeth too, and is crucial for continued immature-root development.
• Cover the pulp wound with non-setting calcium hydroxide or a non-staining calcium silicate cement; restore or reattach the fragment after pulp treatment.
• In a mature tooth needing a post for crown retention, root canal treatment is preferred.
• Review at 6–8 weeks, 3 months, 6 months, and 1 year.

Crown-root fractures

• Assess subgingival extent, bone relationship, restorability, and crown-root ratio; apical extension may be difficult to see radiographically.
• Temporarily stabilize a loose fragment to adjacent teeth or the stable fragment while planning definitive care.
• Without pulp exposure: consider removing the mobile coronal fragment and restoring; seal exposed dentin.
• With exposure: favor partial pulpotomy in immature teeth; attempt dental dam isolation despite subgingival extension. With complete root formation, pulp removal is usually indicated.
• Definitive options depend on age, cooperation, and fracture extent: orthodontic extrusion with restoration, sometimes periodontal recontouring; surgical extrusion; root canal treatment if indicated with restoration; root submergence; intentional replantation with/without root rotation; extraction; or autotransplantation.
• Review at 1 week, 6–8 weeks, 3 months, 6 months, 1 year, then annually for at least 5 years. Monitor restoration, periodontal/marginal bone health, pulp status, and immature-root development.

Manage root and alveolar fractures

Root fracture

• Mobile/displaced coronal fragment, sulcular bleeding, and tenderness may occur.
• Use multiple projections; consider CBCT if conventional imaging is insufficient.
• Reposition a displaced coronal fragment promptly and verify radiographically.
• Passive flexible splint: 4 weeks; cervical fractures may need stabilization up to 4 months.
• Do not initiate endodontics at the emergency visit.
• Do not remove a cervical coronal fragment simply because it is fractured, especially if stable.
• If later necrosis/infection develops, it usually affects the coronal fragment: treat that segment only; an apical barrier may be needed.
• The apical segment rarely needs treatment.
• A very mobile mature cervical fragment above the alveolar crest may require removal and restorative/extrusion/surgical planning.
• Root-fracture reviews: 4 weeks, 6–8 weeks, 4 months, 6 months, 1 year, then annually for at least 5 years.
• Remove splint at 4 weeks for middle/apical fractures, or at 4 months for cervical fractures.

Alveolar fracture

• Several teeth move together; segment displacement and occlusal disturbance are characteristic.
• Reposition the segment, suture gingival lacerations, and splint for 4 weeks.
• Emergency root canal treatment is contraindicated for an alveolar fracture.
• Monitor each involved tooth and bone/soft tissue healing; review at 4 weeks, 6–8 weeks, 4 months, 6 months, 1 year, then annually for at least 5 years.

Choose care by displacement injury

Concussion

• Tender tooth with normal mobility and no displacement.
• No active treatment; review at 4 weeks and 1 year, preferably monitor longer.

Subluxation

• Increased mobility without displacement, possibly sulcular bleeding.
• Usually observe; splint for up to 2 weeks only if excessive mobility or biting tenderness.
• Review at 2 weeks, 12 weeks, 6 months, and 1 year.

Extrusion

• Elongated, mobile tooth with widened apical/lateral periodontal ligament space.
• Gently reposition under local anesthesia; splint 2 weeks.
• Marginal bone fracture/breakdown warrants 4 additional weeks of splinting.
• Extrusion table recommends monitoring and treating necrosis/infection according to root development; general endodontic guidance also says early treatment is typically advisable for severely extruded mature teeth.

Lateral luxation

• Often palatal/lingual displacement with socket-wall fracture; tooth may be locked, immobile, and metallic on percussion.
• Disengage and reposition under local anesthesia; splint 4 weeks, potentially longer with marginal bone/socket-wall fracture.
• At approximately 2 weeks, reassess laterally luxated pulp.
  • Open apex: allow possible revascularization; initiate suitable endodontics if necrosis/infection with inflammatory resorption develops.
  • Closed apex: necrosis is likely; start root canal treatment with anti-resorptive medication.
• Endodontic distinction: IADT 2020 gives this early complete-root treatment pathway and also cautions against treatment solely for a negative sensibility response.
• Base the pathway on the injury and root development; a negative test alone does not diagnose necrosis.
• Extrusion/lateral luxation reviews: 2, 4, 8, and 12 weeks; 6 months; 1 year; then annually for at least 5 years.

Intrusion: apex and depth decide

• Tooth is displaced apically, often immobile with metallic percussion; periodontal ligament space may disappear radiographically.

• Mature intruded pulp almost always becomes necrotic. Start root canal treatment at 2 weeks, or when position permits access, using calcium hydroxide or corticosteroid/antibiotic intracanal medication to prevent inflammatory resorption.
• Reviews: 2, 4, 8, and 12 weeks; 6 months; 1 year; then annually for at least 5 years. Table marks splint removal at 4 weeks where applicable.

Choose pulp care by injury and root maturity

• Cold/electric tests measure neural response, not blood flow; trauma and immature innervation can cause transient false negatives. Test initially and at every review; interpret trends with clinical/radiographic findings.
• Pulse oximetry assesses blood supply but dental sensor/penetration limitations restrict use. Laser/ultrasound Doppler methods are promising.
• Pulp canal obliteration often indicates surviving tissue, particularly after severe open-apex luxation or root fracture; do not equate it with necrosis.
• Open-apex teeth: generally avoid root canal treatment without evidence of necrosis or periapical infection. Intrusion plus crown fracture increases risk enough that immediate/early treatment may be considered. Apexification or revascularization/revitalization are options when treatment is needed.
• Mature severe luxations: general guidance favors early endodontics.
  • Calcium hydroxide may be placed 1–2 weeks after trauma for up to 1 month, then obturated.
  • Alternative corticosteroid/antibiotic paste: place immediately/as soon as possible after repositioning and retain at least 6 weeks; avoid access-wall contact to reduce discoloration.
• Established infection-related external resorption: initiate root canal treatment immediately. Calcium hydroxide for 3 weeks, replaced every 3 months until lesion radiolucencies resolve; obturate when radiographic bone repair is visible.
• Use dental dam for endodontics; retain on neighboring teeth or use stabilizing cords to avoid further injury/fracture.

Splint safety, home care, and surveillance

• Passive flexible splints support comfort, controlled function, and healing. Wire-composite splints can use stainless steel wire up to 0.4 mm; keep composite/bonding away from gingiva and proximal spaces.
• Systemic antibiotic evidence is limited for luxations; none shows improved root-fracture outcomes. Consider associated soft tissue/surgical injuries and medical status individually.
• Counsel patient/guardian: attend reviews, avoid contact sports, maintain meticulous hygiene, and use an antibacterial rinse such as 0.12% chlorhexidine gluconate.
• At reviews assess symptoms, examination, radiographs, sensibility, and photographs. Track pulp infection/necrosis, root development, obliteration, inflammatory/replacement resorption, ankylosis, and marginal tissue/bone breakdown.
• Record generic and injury-specific core outcomes; favorable healing includes function, tissue/bone repair, and continued immature-root development. Explain warning signs and arrange appropriate expertise for complications.
• Source resources: IADT publications/website, ToothSOS, and Dental Trauma Guide.

Common board traps

Answer aloud

An immature incisor is intruded 5 mm and initially tests negative. What next?

Allow re-eruption regardless of depth; establish imaging/test baselines and close follow-up.

• Begin orthodontic repositioning if no re-eruption within 4 weeks.
• Treat demonstrated infection/resorption promptly; a concomitant crown fracture changes risk and may justify earlier endodontics.

A displaced middle-third root fracture is found. What is your emergency plan?

Reposition the displaced coronal fragment promptly and verify its position radiographically.

• Use a passive flexible splint for four weeks for this middle-third fracture.
• Do not start endodontics at the emergency visit; monitor healing.
• If coronal necrosis/infection develops, treat that segment only.

A closed-apex incisor is locked palatally. How do you manage it?

Diagnose lateral luxation/socket injury, disengage and reposition under anesthesia, splint 4 weeks, and arrange an endodontic evaluation at about 2 weeks.

• IADT's complete-root pathway recommends root canal treatment with anti-resorptive intracanal medication.
• This indication follows the injury and root maturity; one negative sensibility test alone does not establish necrosis.
• Schedule long-term surveillance. IADT 2020.

How does a suspected luxation change follow-up after a complicated permanent-incisor crown fracture?

An isolated complicated crown fracture is reviewed clinically and radiographically at 6–8 weeks, 3 months, 6 months, and 1 year.

• If luxation is suspected or confirmed, its injury-specific recall regimen takes precedence and longer surveillance is needed.
• Assess associated injury when the fractured tooth is tender, mobile, or displaced. IADT 2020 and.

How does intrusion depth change repositioning in a closed-apex permanent incisor?

Use depth to select repositioning, and plan early endodontics independently.

• Mature intruded pulp almost always becomes necrotic: start root canal treatment at two weeks or when position permits access.
• Use anti-resorptive intracanal medication and long-term injury-specific surveillance.

An immature permanent incisor has a complicated crown fracture. Is immediate root canal treatment required?

No. Preserve viable pulp when appropriate, commonly with partial pulpotomy, to allow continued root development.

• Pulp capping is another source option; assess associated luxation and restorability.
• Use non-setting calcium hydroxide or non-staining calcium silicate cement on the pulp wound and restore/reattach the fragment.
• Conservative vital pulp treatment can apply to mature teeth too; a mature tooth needing a post for crown retention favors root canal treatment.