Review of Literature

1.1 Terminology:
Trauma is a hurt, a wound, an injury damage impairment, external violence
producing bodily injury or degeneration. Injury means insult, harm, or hurt applied
to tissue that may evoke dystrophic and/or inflammatory response from the
affected part, while tooth injury is defined as damage to the tooth when excessive
force is placed on it (Zwemer, 1982). A tooth injury is a fracture, Luxation or
avulsion, although a combination of injuries may occur in the tooth (Sullivan,
2002).

1.2 Classification of Traumatic Dental Injuries:

Accumulating and comparing data from different studies is extremely
difficult due to the differences in the definitions and classifications used. In a
review made by (Feliciano and de Franca, 2006) a significant number of
classification systems was identified (total= 54), and some were mentioned or used
only once (by the original author). The followings are some of these classification
systems:

1.2.1 Sweet's Classification:

One of the earliest classification systems was suggested by Sweet (1942)
which was consisted of five categories started from "simple enamel fracture
without exposing the dentin" to "fracture of tooth with pulp exposure" taking in
consideration the apex of the root if it is closed or opened, the author depended
on radiographical examination to study each case of fracture. However, this was
not always practical especially in surveys of large population.

Chapter One: Review of Literature 4

1.2.2 Ellis's Classification:
The Ellis classification has been used by various authors for recording
dental trauma. This system is a simplified classification which groups many
injuries and allows for subjective interpretation by including broad terms such as
"simple" or "extensive" fractures. Injuries to the alveolar socket and fractures of
the mandible and maxilla are not classified here.
At first this classification was consisted of five categories started from
"fracture of the crown involving enamel only" to "total tooth loss due to trauma",
although radiograph was not used. Later on, modification of the classification had
done by Ellis herself many times increasing the classification objectivity as it
discussed both primary and permanent teeth using radiograph which makes it
more generalized (Ellis, 1945). Although the index in the last generation
becomes consisted of eight categories started from "simple fracture of crown
involving enamel" to "fracture of the crown en masse and it is replacement",
only the first three classes were commonly described in the emergency literature
(Ellis, 1960).

1.2.3 World Health Organization's Classification:

The WHOs classification of oral trauma, described injuries to the internal
structures of the mouth, it consisted of ten categories starting with "fracture
involving the enamel only and includes enamel chipping and incomplete fractures
or enamel cracks" and ending by "other injuries including laceration of the oral soft
tissues" these broad groups which incorporated with the WHO standards are often
an open ended groupings which may lend themselves to misinterpretation by
investigators (WHO, 1978).

1.2.4 Andreasen's Classification:

This classification which contains nineteen groups including "injuries to the
hard dental tissue and the pulp, supporting bone, gingiva and oral mucosa".

Chapter One: Review of Literature 5

Although this classification is a modification of the WHO's classification, it is a
more comprehensive system which allows for minimal subjective interpretations
because it is based on anatomical, therapeutic and prognosis considerations. This
classification can be applied to both the permanent and primary dentitions
(Andreasen, 1981).

1.2.5 Godoy's Classification:

This classification on traumatized tooth, published by Garcia-Godoy (1981)
consisted of thirteen categories and it is also a modification of the WHOs
classification. Nevertheless, the former separates the dental fractures in those with
or without cementum involvement. Broad terms, such as those used by Andreasen
(1981) are not included in this classification (e.g. complicated and uncomplicated
fractures). There are no groups for subluxations, alveolar injuries, mandibular or
maxillary fractures. The luxations are considered in cases with loosening but with
no displacement.
In this classification there is no overlapping as injuries can be recorded
more accurately, especially for the pediatric dental practice. This index was
widely used in previous Iraqi studies (Yagot et al, 1988; El-Samarrai, 1989;
A1-Sayyab et al, 1992; Al-Hayali, 1998; Al-Obaidi and Al-Geburi, 2002; Al-
Obaidi and Al-Mashhadani, 2002).

1.2.6 Skaare's and Jacobsen's Classification:

Recently Skaare and Jacobsen (2003b) applied a new classification system
and the severity of the injuries was classified as follows:
Mild injury: Enamel infraction, enamel fracture, enameldentin fracture,
concussion, subluxation (horizontal mobility).
Moderate injury: Complicated crown fracture (pulp involved), uncomplicated
crownroot fracture, root fractures in apical or middle one-third without luxation
of coronal fragment, subluxation (vertical mobility).

Chapter One: Review of Literature 6

Severe injury: Complicated crownroot fracture (pulp involved), root fracture in
cervical one-third, root fracture in middle or apical one-third with luxation of
coronal fragment, extrusive luxation, lateral luxation, intrusive luxation, avulsion
(exarticulation).

1.3 Epidemiology of Dental Trauma:

1.3.1 Prevalence:
Prevalence is defined as the number of events, in this case the number of
children experiencing dental trauma, in a given population at a designated time
point (Last, 1995). In general oral injuries are the fourth most common area of
body injuries among 7-30 year old (Peterson et al, 1997). The prevalence of dental
trauma in various epidemiological studies has also been found to differ
considerably. The great variation may be due to a number of different factors such
as the trauma classification, the dentition studied, geographical and behavioral
differences between study locations and countries (Bastone et al, 2002).

1.3.1.1 Clinical and Hospital based Studies:

Traumatic dental injuries were of interest to dental educators, clinicians, and
coordinators of emergency healthcare services; studies focused on visits to dental
clinics and hospitals for emergent dental problems resulting from trauma due to its
importance and subsequent complications on teeth and surrounding tissues (Zeng
et al, 1994). Many clinical and hospital based studies were conducted around the
world concerning the type and severity of the traumatic dental injuries (Liew and
Daly, 1986; Oikarinen and Kassila, 1987; Zeng et al, 1994; Caliskan and Turkun,
1995; Caldas and Burgos, 2001; Sandalli et al, 2005; Jackson et al, 2006;
Andreasen et al, 2006).
Battenhouse (1988) studied the traumatic injury of anterior teeth in
emergency room at children's hospital of Pittsburgh in Medical College of Georgia
and reported 46% of the 1456 patient recorded emergency visit, with boys

Chapter One: Review of Literature 7

representing a significantly higher percentage of trauma visits than girls, and
observed that the etiology of traumatic injuries was mostly due to falls in youngest
age groups. For older children's injuries, athletic activities or fighting were the
primary cause. El-Samarrai (1995) conducted a study among the children attending
clinic of pedodontics in Baghdad University through an eight weeks period and
reported that children with traumatized teeth formed 34.88% of the total children
examined. For both primary and permanent anterior teeth, the upper central
incisors were the most commonly injured teeth followed by the upper lateral
incisors, and treatment was not needed in 13.18% of the examined children with
injured teeth.
Fried et al (1996) in a study done from the dental records at the Montreal
Children's Hospital, Montreal, Canada, the highest incidence of trauma was in
males between the ages of 3 and 4 year, and in females between 1 and 3 year. The
highest incidence of trauma (66.2%) involved the primary central incisors. The
most common cause of trauma (52%) was simple falls indoors. Gassner et al
(1999) carried out a study to evaluate the overall place of dental trauma in facial
injuries. The incidence of dental injuries with respect to the total number of facial
injuries was as follows: 57.8% in play and household accidents, 50.1% in sports
accidents, 38.6% in accidents at work, 35.8% in acts of violence, 34.2% in traffic
accidents, and 31% in unspecified accidents. The overall incidence revealed was
48.25%.
In a study conducted by Rajab (2003) at the teaching clinics of the
Department of Pediatric Dentistry, University of Jordan, the percentage of
traumatic dental injuries was 14.2% from 2751 subjects. The dental records of all
patients aged 7-15 years were recorded over a period of 4 years. The peak
incidence of injury was 10-12 year age group. Boys were more affected (18.3%)
than girls (10.1%). Most injuries occurred at home (63.2%) and falls were the
leading cause of injuries (49.9%). Most injuries involved one tooth (69.3%) and
maxillary central incisors were the most affected teeth (90.4%). The commonest
injury was uncomplicated crown fracture (62.5%).

Chapter One: Review of Literature 8

 Zuhal et al (2005) investigated 514 traumatized permanent incisors in 317
patients (114 girls and 203 boys), aged between 6 and 17 years, over 3-year period
at the Department of Pedodontics, Sleyman Demirel University School of
Dentistry. In all age groups, the most frequent cause of trauma was found to be
unspecified falls (47.6%). Maxillary teeth (88.5%) and central incisors (87.5%)
were the most affected teeth from dental trauma. Ellis class II crown fracture was
the most frequently seen type of injury (43.8%).

1.3.1.2 Population based Studies (Surveys):

Many epidemiological studies had been established around the world to
study the prevalence and incidence of dental injury for primary and permanent
teeth, some of these studies are as follows:

1.3.1.2.1 European Studies:

There is an obvious contradiction present in the literature regarding the
frequency of traumatic injuries to primary and permanent teeth. Different
frequencies had been reported in many Scandinavian countries. In a Swedish
population of 718 children, 12 children (1.7%) had sustained injuries to primary
teeth (Gerdin, 1969). In another Swedish population a frequency of 12.5% was
recorded (Lind et a1, 1970).
O'Mullane (1973) conducted a study on 2792 subjects aged between 6-19
years in an Irish urban community and reported a prevalence of injured permanent
incisors of 12.5% and the main cause was organized contact sports. Other
investigations among England (Grundy, 1959) and Scotland (McEwen et al, 1967)
populations reported a prevalence of 5.9% and 8.2% respectively. Some other
European studies are summarized in Table (1-1).

1.3.1.2.2 American Studies:

Many studies had been conducted in the North and South America to study
the prevalence and incidence of injured anterior teeth.

Chapter One: Review of Literature 9

 Table (1-1): Summaries of some European studies

Prevalence
Country Reference Age/ years
%
Sweden Forsberg and Tedestam (1990) 7-15 30
Sweden Josefsson and Karlander (1994) 7-17 11.7
France Delattre et al (1995) 6-15 13.6
Finland Petti et al (1996) 6-16 21
UK Hamilton et al (1997) 11-14 34
UK Marcenes and Murray (2001) 14 23.7
Norway Skaare and Jacobsen (2003a) 7-18 1.8
Norway Skaare and Jacobsen (2005) 1-8 1.3

In one of the earliest studies; Kramer (1941) conducted his investigation on

11500 students aged 16-20 year old and reported a prevalence of injured teeth to be
27%. Garcia-Godoy (1981) conducted a study to investigate traumatic injuries to
primary teeth of preschool children from the south eastern part of Dominican
Republic and found a prevalence of 35%. While other study on Dominican
population also, recorded a prevalence of 16.6% (Sanchez et a1, 1981), this
difference between these two studies may be due to socioeconomic aspects.
Kania et al (1996) conducted a study on 3396 third and fourth grade school
children in Alachua County, Florida, aged 6-12 year old and found that one in five
(19.2%) exhibited some degree of incisor injury, while Alonge et al in 2001
conducted a study among 1039 students in Harris County, Texas, and reported a
prevalence of 2.4% for incisal fractures. In Brazil, Traebert et al (2003a) reported a
prevalence of 10.7% among a sample of 2260 (11-13 year old) schoolchildren.
While Soriano et al (2004) reported a prevalence of 23.3% among a random
sample of 116 boys and girls aged 12 years, attending both public and private
schools. On the other hand, the prevalence was 17.3% among 12-year-old

Chapter One: Review of Literature 10

schoolchildren (Traebert et al, 2006). In a recent study among Grade 8 children in
Ontario communities, Canada, 3010 children attending 66 schools were examined
and damage to the anterior dentition was observed in 18.5% of the cases (Locker,
2005).

1.3.1.2.3 New Zealand, Australian and Asian Studies:

Beck (1968) reported a prevalence of 9.4% injured teeth in New Zealand
adolescents and young adults and supposed the major cause of injury were
falls and contact sports, while Dearing (1984) observed a prevalence of (19%)
for traumatized incisors among New Zealand children. Stockwell (1988)
conducted a study in Western Australian School dental service, the population
comprised 66500, 6-12 year old children. 1.66 children and 2.05 teeth per 100
children received trauma. The incidence resulting from falling or being pushed
and a bicycle accident caused a higher than average rate of multiple trauma
and pulpal exposure.
In Japan, Kikuchi and Kawakami (1957) reported a prevalence of 5.7% in
Japanese population and the playing and sports were the major causes of
trauma especially fighting types of sports. While, Uji and Teramoto (1988)
conducted a survey by sending questionnaires to 15822 school-aged boys and girls
6-18 years of age and found that an average of 21.8% of the pupils suffered from
some kind of trauma in the oral region. Rai and Munshi (1998) examined 4500
school children in the age group of 3 to 16 years from South Kanara District of
Karnataka, India. A total of 238 cases (5.29%) had incisor and canine fractures and
the leading cause of injury was undefined falls. While recently Gupta et al in 2002
reported a prevalence of 13.8% for traumatic injuries to the incisors in children of
South Kanara District.
In Jordan, Hamdan and Rock (1995) examined 459 schoolchildren, 234 from
urban Amman and 225 from rural South Shouna, aged 10-12 years for injuries to
permanent incisors reported the prevalence of injuries in Amman was 19.2% and in
South Shouna was 15.5%. On the other hand, Hamdan and Rajab (2003) found a

Chapter One: Review of Literature 11

prevalence of dental trauma to be 13.8% among 1878 schoolchildren aged 12 years
examined in urban and rural schools.
In a Syrian study done by Marcenes et al in 1999 conducted on 1087
children aged 9 to 12 years selected from primary schools in Damascus, the
prevalence of traumatic injuries to the permanent incisors rose from 5.2% at the
age of 9 years to 11.7% at the age of 12 years. Al-Majed et al (2001) demonstrated
that the prevalence of dental trauma in 354 Saudi boys aged 5-6 years was 33%
and was 34% in 862 among 12-14 year old boys attending 40 schools in Riyadh.
Nik-Hussein (2001) reported a prevalence of injury to the anterior teeth was 4.1%
among 4085 schoolchildren aged 16 years examined in Malaysia. Artun et al
(2005) studied 1583 Kuwaiti children, 795 girls and 788 boys, and reported a
trauma prevalence of 19.3% in boys and 9.7% in girls.

1.3.1.2.4 African Studies:

In a study on 3507 Sudanese children who were residents of Khartoum
Province aged 6-12 year old, Baghdadi et al (1981) reported the prevalence of
injured anterior teeth was 20.1% represented by 16.5% and 3.6% for the boys and
girls respectively. Ohito et al (1992) from Nairobi, Kenya reported a prevalence of
11% among normal children in a study conducted on 2791 normal and
handicapped children aged 5-15 years. Otuyemi (1994) in an investigation of 12-
years-old Nigerian children reported that the prevalence of dental injuries was
10.9%. In another study by Otuyemi et al in 1996 among 1-5 year old children
recorded that 30.8% had injured teeth due to trauma. Kahabuka et al (2001) in a
study conducted among 4524 children aged 4-15 years in Dar es Salaam, Tanzania,
found that 21% of all children examined, at least one type of untreated dental
trauma was observed.
Hargreaves et al (1995) reported a prevalence of 15% among 11 year old
children in South Africa in his study on 1035 children. While, recently in a
Nigerian study done among 1600 of 12 year old school pupils, a prevalence of

Chapter One: Review of Literature 12

9.8% has been reported for traumatic fractures of anterior teeth (Agbelusi and
Jeboda, 2005).

1.3.1.2.5 Iraqi Studies:

Many Iraqi studies had been conducted on the traumatized anterior teeth
from the beginning of 1980's, some of them were epidemiological studies
concerning prevalence, incidence, gender and age variation and some were clinical
concerning management of emergency cases in hospitals.
Baghdadi et al (1981) found that the prevalence of traumatic tooth injuries
was 7.7% for 6-12 year age groups in a study carried out on 6090 primary school
children from Baghdad city. While, Yagot et al (1988) reported a high prevalence
for injured anterior teeth among 2398, 1-4 year old children which was 24.4% in
Baghdad city. On the other hand, E1-Samarrai in 1989 reported a prevalence of
27.82% among 1438, four and five year old, children in Baghdad. A1-Sayyab
(1992) in his survey on traumatized anterior teeth in rural areas included 306
children; their age ranged from 2-13 years and showed that 15.3% of the sample
had dental injuries.
A study in both urban and rural areas in the central region of Iraq among
7213 children of 4-15 year of age was conducted by Al-Hayali in 1998 and
reported a prevalence of 29.6% for the total sample examined, while a prevalence
of 14% was reported among 285 subjects of 5-30 year old in Sheha village in
Baghdad (Al-Obaidi and Al-Mashhadani, 2002). Recently Al-Kassab (2005)
performed a study in Mosul city among 10915, 6-15 year old, children and
teenagers and reported 5.4% prevalence for dental trauma, but in this study only
crown fractures in incisor teeth were counted for trauma.

1.3.1.3 Variables Affecting the Prevalence:

1.3.1.3.1 Age and Causes of Trauma Occurrence:
A wide disagreement exists when reviewing the literature for the age at
which the subject is most susceptible to traumatic dental injuries of anterior teeth

Chapter One: Review of Literature 13

and its effects and relations (Taatz, 1967; Al-Hayali, 1998; Cortes et al, 2002), as
well as, the etiology of dental injury varied in its types according to the older age
of the patient (Baghdadi, 1981, Skaare and Jacobsen, 2003b). Differences in
sampling technique and application of diagnostic criteria could be responsible for
the varying prevalence rates of traumatic dental injuries among studies in relation
to age, as well as, regarding the age there is a variation between studies and
countries for the predominant causes of dental trauma, while there's no absolute
age-cause relation (Andreasen, 2000).
Falls were reported to be the most common cause of trauma affecting
preschool children especially at 1.5 and 2.5 years due to lack of experience in
walking and disorientation of muscular activity. This suggestion agreed with many
others like (Andreason and Ravn, 1972; Baghdadi et al, 1981; Yagot et al, 1988;
Fried et al, 1996; Wilson et al, 1997; Gassner et al, 2000; Blagojevic et al, 2005).
This may be attributed to the fact that as a child starts to walk and run the
incidence of dental injury increases until an initial peak around the age of 4 years,
followed by a second peak at the age of 8-10 year (Andreasen and Andreasen,
1994). Iraqi studies have shown that falls and sports are the major cause of injury
especially for aged 6-12 year old (Baghdadi et al, 1981; Yagot et al, 1988; Al-
Kassab, 2005).
Epidemiological studies showed that approximately 30% of all children
under the age of seven have sustained injuries to one or more of their primary
incisors (Borum and Andreasen, 1998; Odersjo and Koch, 2001). Most of the
injuries to the primary dentition and the more serious ones happen in the ages 2-4
years (Selliseth, 1970; Ravn, 1975; Soporowski et al, 1994). Onetto et al (1994)
reported that 10-12 year old children had the highest number of injuries and falling
was the most common cause of injury in both primary and permanent dentition
groups, followed by striking against objects and bicycle accidents in permanent
dentition.
Iraqi studies also discussed this subject and found a significant increase in
the prevalence of trauma associated with advancing age of children. At the age of

Chapter One: Review of Literature 14

one year, 17.3% of children was with traumatized teeth increased to 34.0% and
41% in 2 and 3 year of age respectively (Yagot et a1, 1988), while E1-Samarrai
(1989) showed no significant difference between four and five year old children.
Playing sports is a well known cause of dental trauma (Hunter et al, 1990;
Jolly et al, 1996; Gassner et al, 2000; Gabris et al 2001) and sports-related dental
trauma differs from other dental trauma that occurs in general population because
its prevention is possible (Ranalli, 2002). An important factor found to increase the
risk of dental trauma is the lack of a properly fitted mouthguard and/or faceguard
while playing sports (Welbury and Murray, 1990; Padilla et al, 1996; Rodd and
Chesham, 1997). The value of mouthguards may be demonstrated by Lee-Knight
et al (1992), who reported that none of the athletes who sustained dental injuries in
the Canada Games was wearing a mouthguard. Johnsen and Winters (1991)
suggest that many dental injuries can be avoided by informing the population of
the importance of these protective devices whilst playing sport. Jolly et al (1996)
observed that when a mouthguard was not worn during football games, the
likelihood of a fractured or avulsed tooth was at least twice that of when a
mouthguard was worn. It was made clear by many studies that mouthguards should
be worn by any athlete, professional or amateur, who plays any sport with any risk
of falls, blows or contact with rigid surfaces, even if the sport is not recognized as
a violent one (Maestrello-deMoya and Primosch, 1989; Ferrari and Medeiros,
2002; Lang et al, 2002).
Obesity or overweight is also been suggested as a predisposing factor to
dental trauma. A significant inverse correlation between obesity and trauma-
predisposing behavior were found by Petti et al (1997) and suggested that subjects
frequently playing sports and lively games were not only less obese, but also more
skillful and, for this reason, less prone to trauma when they fell or sustained
impacts and obese children being claimed to be less skilful and more likely to have
their anterior teeth traumatized (Nicolau et al, 2003). On the other hand, Soriano et
al (2004) reported no associations between obesity and dental trauma and

Chapter One: Review of Literature 15

nutritional status showed no significant effect on dental trauma in Al-Kassab
(2005) study.
Adverse psychosocial environment and lower socio-economic status were
among the factors which were found to predispose dental injuries (Hamilton et al,
1997; Nicolau et al, 2003). Other than these factors, hyperactivity and aggressive
behavior were reported to be associated with the occurrence of major injuries
affecting the face and/or teeth (Lalloo, 2003; Lalloo and Sheiham, 2003; Al-
Kassab, 2005; Sabuncuoglu et al 2005).

1.3.1.3.2 Gender Variation:

Most of the studies conducted around the world have concluded that males
are more affected by traumatic dental injuries than females (Liew and Daly, 1986;
Kaba and Marechaux, 1989; Marcenes et al, 2001; Al-Obaidi and Al-Mashhadani,
2002; Al-Obaidi and Al-Geburi, 2002; Traebert et al, 2003a; Artun et al, 2005; Al-
Kassab, 2005).
Forsberg and Tedestam (1990) reported a higher trauma frequency in boys
than in girls in both primary and permanent dentition, the gender ratio being 1.2:1
in the deciduous dentition and 1.6:1 in the permanent dentition. While other
investigations showed that males experienced double the percentage of incisal
injuries compared to females (Marcenes et al, 2000; Skaare and Jacobsen, 2003a).
In many other studies the difference in gender distribution among children in
the primary dentition has not been so obvious. Onetto et al (1994) observed that the
male:female ratio was 0.9:1 for children less than seven year old and assumed that
the number of dental trauma in girls may be rising due to the increasing number of
girls who participate in sports that in the past were practiced only by boys. The
same results were reached by Davis and Knott (1984) and Brin et al (1984).
Other researchers indicated that there was no significant difference in the
prevalence of traumatic injuries between males and females (Garcia-Godoy, 1984;
Yagot et al, 1988; El-Samarrai, 1989; Bijella et al, 1990; Otuyemi, 1996; Marcenes
et al, 1999; Rocha and Cardoso, 2001).

Chapter One: Review of Literature 16

1.3.1.3.3 Lip Condition:
Competent lip coverage have been discussed by many authors and claimed
to be an important predisposing factor for traumatic dental injuries (Ellis, 1945;
Baghdadi et al, 1981; Kania et al, 1996).
Sweet (1942) reported that 90% of all children with incomplete lip coverage
had fractured anterior teeth. Burden (1995) observed that children with inadequate
lip coverage were at greater risk of dental trauma and indicated that inadequate lip
coverage is the single most important independent predictor of traumatic injury,
regardless of their overjet size. Marcenes et al (1999) showed that Syrian children
with inadequate lip coverage were more likely to have experienced dental injuries
than those with adequate lip coverage and Artun et al (2005) showed that lip
incompetence was more frequent among the subjects with injured maxillary
incisors (12.7%) than among those without injuries (7.3%). On the other hand,
Hunter et al (1990) did not observe an increased frequency of dental trauma with
incompetent lip closure, particularly in females. Many authors noted that there was
no association between inadequate lip coverage and traumatic dental injuries
(Marcenes et al, 2000; Traebert et al, 2003a).
Ghose et al (1980) found that, in Iraqi and Sudanese children, simple
enamel fracture was more predominant in cases of adequate lip coverage,
while severe types of injuries like fracture of the crown involving the pulp and
missing of the tooth were highly found in cases of inadequate lip coverage in
both genders. Al-Hayali (1998) showed that lip position is a highly significant
factor in dental injury and the same conclusion was reached by Al-Kassab (2005).

1.3.1.3.4 Occlusal Relationship:

1.3.1.3.4.1 Types of Occlusion:
According to Angles classification (1899) there are three classes of
occlusion depending on the occlusal relationship of the permanent first molar:
1. Class I occlusion: The mesio-buccal cusp of the upper first permanent molar
occludes with the mesio-buccal groove of the lower first permanent molar.

Chapter One: Review of Literature 17

 2. Class II malocclusion: The lower first permanent molar distally positioned by
at least one-half cusp relative to upper first permanent molar.
3. Class III malocclusion: The lower first permanent molar mesially positioned
by at least one-half cusp relative to upper first permanent molar.
Canine classification system includes three basic classes similar to Angles
classification (Foster, 1984):
1. Class I: The tip of the maxillary canine lies in the embrasure between the
mandibular canine and the first premolar.
2. Class II: The tip of the maxillary canine lies one half of a cusp mesial to the
embrasure between the mandibular canine and the first premolar.
3. Class III: The tip of the maxillary canine lies one half of a cusp distal to the
embrasure between the mandibular canine and the first premolar.
Most of the studies on traumatized teeth are treatment oriented and it is in
the recent decade studies have concerned about the predisposing factors of
traumatic dental injuries.
Glucksman (1941) explained that dental injury of one or more anterior teeth
is so common in certain types of malocclusion, especially class II division I, and
Tulley (1966) showed that children with class II division I type of dentition were
the most susceptible to all forms of incisor trauma. Brin et al (1984) stated that
"children with class II malocclusion in their primary dentition might be more
susceptible to trauma". The severity of injuries appeared to increase when there
was an associated injury to the lower lip, while one third of the accidents occurred
in subjects with some form of malocclusion. Female subjects with prominent
maxillary incisors and incompetent lip closure often had multiple injuries to the
supporting structures of the teeth (Galea, 1984).
O'Mullane in 1973 reported that the frequency of traumatically injured teeth
being higher in class II division 1 dentition than in other types of occlusion.
Further more, the risk of incisor injury was greater for children who had a
prognathic maxilla (Kania et al, 1996). The same results were reported by Iraqi
studies (Al-Hayali, 1998; Al-Kassab, 2005).

Chapter One: Review of Literature 18

1.3.1.3.4.2 Overjet:
Overjet is considered to be the most important indicator for dental
occlusion especially in an anterior-posterior dimension "sagittal plane" affecting
both esthetics and function (Kowalski and Prahl-Andersen, 1976; Foster, 1984).
Kinaan (1977) defined overjet as "The distance between the most labial aspect
of the surface of the most prominent lower incisor and the labial surface of
incisal edge of the most prominent upper incisor provided that teeth are in
centric occlusion".
Different scoring criteria and different normal range values have been
suggested by different authors and investigators which make the results of
different studies to vary considerably. Foster and Day (1974) described overjet
in the following criteria, normal 1-3 mm, increased more than 3mm, edge to
edge, reversed and instanding. Jarvinen (1978) and Isiekwe (1983) described a
near range value (0-3 mm) for normal range. Some investigators suggested a
normal overjet value between 2-4 mm (Kinaan, 1977; Corruccini et al, 1983;
Hassanali and Pokhariyal, 1993). While others considered a range value between
0-6 mm for a normal overjet (Bjork et al, 1964; Oreland et al, 1987).
Many studies are available concerning the relationship between traumatic
injuries to the anterior teeth and increase overjet. Protruded teeth have been
claimed to increase the risk of traumatic dental injuries to the anterior teeth
(Jarvinen, 1979; Hamdan and Rock, 1995). Ghose et al (1980) and Al-Hayali
(1998) considered anterior teeth to be protruded when the overjet exceeds 5
mm, while Al-Kassab (2005) considered overjet more than 4 mm to be
increased overjet.
O'Mullane (1973) in his study among examined 2792 subjects of Irish
urban communities aged between 6-19 year old reported that the prevalence of
injured incisors was significantly higher in subjects with increased overjet. The
same conclusion was made by other researchers (Baghdadi et al, 1981; Dearing,
1984; Hunter et al, 1990; Kania et al, 1996; Soriano, 2004). Children who had
an incisal overjet greater than 5 mm had more dental injuries than those whose

Chapter One: Review of Literature 19

incisal overjet was less than 5 mm (Cortes et al, 2000; Al-Majed et al, 2001;
Soriano et al, 2004), while Petti and Tarsitani (1996) reported that individuals
with an overjet greater than 3 mm were two and a half times more at risk
compared with individuals who had a normal overjet.
Female subjects with prominent maxillary incisors and incompetent lip
closure often had multiple injuries to the supporting structures of the teeth
(Galea, 1984). Burden (1995) observed that subjects with an overjet greater than
the normal range (0-3.5 mm) were significantly more likely to have received an
injury to the maxillary incisors. It also appeared that the prevalence of dental
trauma in females increased as overjet increased. Artun et al (2005) explained
that the odds of maxillary incisor trauma was 2.8 times higher in subjects with
overjet between 6.5 and 9.0 mm, and 3.7 times higher in subjects with overjet
more than or equal to 9.5 mm than in subjects with overjet more than or equal to
3.5 mm and that the risk increased by 13% for every millimeter of increase in
overjet.
Traebert et al (2006) reported that prevalence of traumatic dental injuries
was 17.3% among 12-year old schoolchildren in Brazil who had an incisal
overjet size more than 5 mm, and this group were 3.5 times more likely to have
dental trauma than children who had an incisal overjet of less than 5 mm. Al-
Hayali (1998) reported that 76% of the children with extreme value of overjet (9
mm) had injured their teeth and Al-Kassab (2005) recorded a prevalence of
traumatized teeth of 59% among subjects having an overjet size of more than
4mm. On the other hand, other researchers reported that increased overjet of the
maxillary incisors is not fully capable of predicting the likelihood of increased
dental injury (Stokes et al, 1995; Brin et al, 2000; Marcenes et al, 2000; Holan
et al, 2005).

1.3.1.3.4.3 Overbite:
Overbite can be defined as the vertical distance from the incisal edge of the
maxillary central incisors to the incisal edges of the corresponding mandibular

Chapter One: Review of Literature 20

central incisors, providing that dental arches are in centric occlusion (Smith and
Bailit, 1979), but Bjornaas et al (1994) defined overbite as the distance from the
incisal edge of the lower incisor to the occlusal plane. Many descriptions for the
overbite have been widely used including, complete (the overlapped incisors
reveals contact between the lower incisors to the palatal surfaces of the upper
incisors or palate), incomplete (no such contact present), edge to edge and open
bite (Foster and Day, 1974).
Normal range values changed according to different authors. Foster and Day
(1974) recorded a value of one-half of the length of the crown of the mandibular
central incisor. Others referred 1-3mm (Farah, 1988) and 2-4mm (Kinaan, 1977;
Hassanali, 1993) as a normal range. Tapias et al (2003) reported that boys and
children with overbite registered a 2.13 and 1.81 fold higher risk of crown
fractures, respectively. Shulman and Peterson (2004) revealed that maxillary
incisor trauma is significantly associated with overjet while mandibular incisor
trauma is associated with overbite. Compared to individuals with 0-mm overbite,
the odds of trauma was significantly greater in subjects with overbites of 3-4 mm
(OR = 2.03) and 5-7 mm (OR = 2.07) but approached unity for >7 mm.
Previous Iraqi studies showed that the prevalence of dental trauma was
significantly associated with increased overbite, were 40% of the subjects having
trauma had an overbite of more than 5mm (Al-Hayali, 1998) and 53% of the
traumatized subjects had an overbite value of more than 4mm (Al-Kassab, 2005).

1.3.1.3.4.4 Open Bite:

The open bite is considered to be a deviation in the vertical relationship of
the dental arches and is characterized by the absence of contact of the incisal
borders of the maxillary and mandibular teeth in the vertical plane (Graber, 1961;
Nanda, 1990). Subtenly and Sakuda (1964) stated that it is a deviation in the
vertical relationship of the maxillary and mandibular dental arches, in which there
is a lack of contact in the vertical direction between opposing segments of teeth.

Chapter One: Review of Literature 21

 Some investigators consider an open bite to be present when there is less
than an average overbite, others consider an edge to edge relationship to be an
open bite, while others specify that should a definite degree of openness must be
present (Salzmann, 1968; Lavelle, 1976; Oreland et al, 1987). Shulman and
Peterson (2004) in their study among subjects of 8-50 year of age claimed that
open bite was not significantly associated with dental trauma. While, Al-Hayali
(1998) reported that the highest prevalence of trauma was among open bite
subjects (60%).

1.3.1.4 Type of Dental Injuries:

In reviewing the literature, various difference exits between studies
concerning the type of dental injuries, a part of this discrepancy may be related to
the method of selecting the sample studied, as for clinical studies in hospitals
severe types of injuries were the most common type (Andreason, 1970; Clement,
1984; Harrington et al, 1988). While, studies based on survey of normal
population simple types of injuries are predominant (O'Mullane, 1973; Baghdadi
1981; Hamdan and Rock, 1995; Al-Majed, 2001, Traebert et al, 2006).
The type and severity of dental injuries per patient differ according to the
patient age and the cause of the accident. Uncomplicated crown fracture (without
pulp exposure) was the most common injury to the permanent dentition in most
studies (Garcia-Godoy et al, 1983; Dearing, 1984; Stockwell, 1988; Forsberg and
Tedestam, 1990; Kania et al, 1996; Alonge et al, 2001; Al-Obaidi and Al-
Mashhadani, 2002; Al-Kassab, 2005). However, subluxations and complete
luxations were the most frequently occurring injuries in two hospital studies,
particularly in the primary dentition (Galea, 1984; Martin et al, 1990).
Displacement (luxation) of teeth has occurred more frequently in the
younger age groups studied (Galea, 1984; Bijella et al, 1990; Onetto et al, 1994;
Osuji, 1996; Wilson et al, 1997; Al-Jundi, 2004; Skaare and Jacobsen, 2005).
Some authors have indicated that the supporting structures (alveolar bone and
periodontal ligament) in the primary dentition are resilient, thereby favoring

Chapter One: Review of Literature 22

dislocations rather than fractures (Judd, 1985; Andreasen and Daugaard-Jensen,
1991; Kirzioglu et al, 2005).
Baghdadi et al (1981) reported the types of injuries to be; enamel (57%),
enamel and dentine without pulp exposure (29%), and tooth missing are 12% in
Iraqi population. Yagot et al (1988) showed that enamel fracture was the most
common type (84%), followed by concussion (7.4%), enamel and dentine fracture
(6.2%), avulsion (1.9%), crown fracture with pulp exposure (0.3%), intrusion
(0.3%) and extrusion (0.1%). These results were closed to some other Iraqi studies
(El-Samarrai, 1989; Al-Sayyab, 1992).
Al-Hayali (1998) reported that most common type of dental injury was
simple enamel fracture (71%), followed by enamel dentine fracture (12%) and
concussion (8%). While enamel, dentine and cementum fracture was the least
common (0.2%). Simple enamel fracture followed by concussion was the most
prevalent types in the primary dentition. While, simple enamel fracture followed
by enamel and dentine fracture then enamel, dentine with pulp exposure were most
common types of injury in the permanent dentition.
Other studies found that the most common type of dental injury was enamel
fracture followed by enamel-dentine fracture without pulpal exposure (Al-Obaidi
and Al-Geburi, 2002; Al-Obaidi and Al-Mashhadani, 2002). Recently, Al-Kassab
(2005) reported that enamel-dentine fracture was the commonest type of crown
fracture (47%), followed by simple enamel fracture (33%), and the least common
type of injury was enamel-dentine fracture with pulp exposure (20%).

1.3.1.5 Type and Number of Teeth involved in Trauma:

Maxillary central incisors were the most frequently injured teeth reported for
both the primary and permanent dentitions. The second most frequently injured
teeth were maxillary lateral incisors followed by the maxillary canines, while the
lower incisors were the least involved by trauma (Galea, 1984; Stockwell, 1988;
Martin et al, 1990; Hargreaves, 1995; Oulis and Berdouses, 1996; Nik-Hussein,
2001; Baus et al, 2004; Soriano et al, 2004; Artun et al, 2005; Traebert et al, 2006).

Chapter One: Review of Literature 23

An exception is in a study done by Forsberg and Tedestam (1990) where
mandibular central incisors were the second most frequently injured teeth.
In a comparative study between Iraqi and Sudanese population, Baghdadi et
al (1981) reported that the maxillary central incisors accounted for 90% of the
dental injury in Iraqis compared with 97% in Sudanese. Equivalent figures for the
maxillary lateral incisors were 1.9% and 2.4% respectively. The frequency of
injury to mandibular central and lateral incisors was found to be 7.5% and 0.6% in
Iraqi children. Other Iraqi studies also reported that the maxillary central incisors
are the most common teeth to be affected by trauma (Yagot et al, 1988; El-
Samarrai, 1989; Al-Obaidi and Al-Mashhadani, 2002; Al-Obaidi and Al-Geburi,
2002). Ellis (1960) and Al-Hayali (1998) reported that the maxillary central
incisors are the most affected by dental trauma followed by mandibular central
incisors and maxillary lateral incisors. While Al-Kassab (2005) found that the
maxillary central incisors are the most affected teeth by trauma followed by
maxillary lateral incisors and the same result was shown by other researchers
(Chen et al, 1999; Canakci et al, 2003).
In a literature review on dental trauma by Bastone et al (2002) noted that the
number of injuries per patient has varied from between 1.1 and 2.0, but this
variation could have been influenced by the actual injuries being recorded, the
classification used and the type of study location. Liew and Daly (1986) and
Martin et al (1990) conducted studies in all age groups from after hour dental
clinics and reported more severe injuries to older patients and injuries involved
more teeth per patient than had been found in another private practice study by
Davis and Knott (1984).
A single tooth injury makes more than half of the cases (Davis and Knott,
1984) or slightly more (Caliskan and Turkun, 1995). While other studies conducted
in hospital casualty departments and after hours clinics have observed injuries to
one and two teeth in equal proportions (Leiw and Daly, 1986; Martin et al, 1990),
or two teeth more frequently than one (Galea, 1984).

Chapter One: Review of Literature 24

 The number of injured teeth per patient also varied between countries and
sites of the studies. The type of study center also affected the frequency of multiple
injuries per person. One tooth was more frequently injured than multiple teeth in
most prospective studies conducted at school dental services and general clinics
(Davis and Knott, 1984; Stockwell, 1988; Onetto et al, 1994; Oulis and Berdouses,
1996). Marcenes et al (1999) in their Syrian study found that 78% had only one
tooth injured, and 17% had two teeth injured, while only 4.6% had three or more
teeth traumatized. Garcia-Godoy (1979) showed that 65% of the total children
examined had one traumatized tooth and 34% had two teeth affected, while only
0.4% traumatized four teeth.
Rajab (2003) reported that 69.3% had only one tooth damaged, 28.6% had
two teeth damaged, and only 2.1% had three or more. The patients had
approximately 1.3 injured teeth per accident. While, Zuhal et al (2005) reported
that the number of injured teeth per child was 1.62 and 46.7% of the patients was
found to have more than one injured teeth. El-Samarrai (1989) concluded that 61%
of the traumatized children had only one affected tooth followed by 32% having
two affected teeth, while only 1.5% was having four traumatized teeth and nearly
similar results was reported by other researchers (Yagot et al, 1988; Al-Kassab,
2005).
Concerning the sides of the jaw that are more affected by trauma, the right
side appeared to be more frequently involved than the left side (Garcia-Godoy,
1979; El-Samarrai, 1989; Al-Obaidi and Al-Geburi, 2002; Al-Kassab, 2005).
While other studies concluded that the left side was more affected than the right
side (Davis and Knott, 1989; Al-Obaidi and Al-Mashhadani, 2002; Saroglu and
Sonmez, 2002). On the other hand, many studies showed that there were no
differences between the right and left side of the jaws concerning dental trauma
(Andreasen, 1970; Skaare and Jacobsen, 2005; Canakci et al, 2003; Kramer et al,
2003; Baus et al, 2004).

Chapter One: Review of Literature 25

1.3.1.6 Place of Trauma Occurrence:
When the child starts walking alone, between 18 and 30 months, the home is
the place where most traumas occur in males and females (Mestrinho and Bezerra,
1998), also Skaare and Jacobsen (2005) reported that most of the injuries occurred
either at home (38%) or at kindergarten (32%). Garcia-Godoy et al (1981) showed
that the most frequent place of occurrence of trauma, in both genders, was at home
(34.1%), followed by outside of home (19.3%) and at school (12.5%) and a similar
result was reported by Apostulovic (2003).
Traebert et al (2003b) reported that the majority of accidents occurred at
home (60.4%) followed by school (18.6%) and outside in the street (18.6%). A
similar result was reached by Rajab (2003) and Traebert et al (2006) and the
former also concluded that boys had more injuries at school and street than girls
and for girls more injuries occurred at home. On the other hand, Stockwell (1988)
and Sgan-Cohn et al (2005) reported no significant differences in regard of having
trauma at school, home or outside home.

1.3.1.7 Season of Trauma Occurrence:

Many studies showed that there is a seasonal variation in the occurrence of
traumatic dental injuries and temperate climates are characterized by increased
number of trauma cases as warm weather draw children outdoors (Perez et al,
1991; Lombardi et al, 1998). The most frequent setting for crown fractures is the
street, and the peak season of the year in summer, due to, in all likelihood, a lower
degree of observation on the part of parents and teachers (Tapias et al, 2003). Al-
Kassab (2005) also reported an increased trend for dental trauma to occur in
summer (57.6%).
Altay and Gungor (2001) observed a slightly higher, but statistically not
significant, in the prevalence of dental trauma occurrence between spring/summer
and winter/autumn (54% and 46%, respectively). A peak month for dental injuries
was reported to be at June (O'Neil et al, 1989). Zeng et al (1994) reported that most
injuries were in late spring and summer and the proportion of trauma varied from

Chapter One: Review of Literature 26

lowest (5.1%) trauma in January to as high as (11.7%) trauma in August. While
Saroglu and Sonmez (2002) reported an increase tendency for dental trauma to
occur in May.
Llarena del Rosario et al (1992) showed that the largest number of injuries
were seen during winter (36%) followed by summer (25%), spring (21%) and
autumn (18%). Further more, seasonal variation may not be an issue in Harris
County, Texas, because of the relatively mild winter seasons (Alonge et al, 2001).
However, Stockwell (1988) did not find any seasonal variation of incisal trauma in
Western Australia.

1.3.1.8 Time Elapsing for Treatment Following Tooth Injury and

Treatment Needs:
From Hamilton et al (1997) viewpoint, children sought care because of pain
and for esthetic reasons. Regarding elapsing time for treatment following tooth
injury, Onetto et al (1994) noted that the time taken to visit a dentist is strongly
related to the educational level of the parents. Two previous studies reported that
77% and 68% of patients attended for treatment in the same day or the day after
trauma occurred (Josefsson and Karlander, 1994; Gabris et al, 2001), respectively,
while, Oulis and Berdouses (1996) observed that 68% of their patients attended for
treatment on the third day after trauma. Nik-Hussein (2001) reported that there was
a high level of fractured anterior teeth that required treatment (91%) among 16
year old school children in Malaysia. Whereas, Rajab (2003) pointed that 40.2% of
children had treatment delay exceeding l month, also the author reported that cases
after along post-traumatic period required more complicated treatment than those
presented within a short time.
Among those children who had experienced traumatic injuries to the teeth,
93.1% presented with untreated damage. Because some injuries were minor, such
as small enamel fractures, the proportion of children who needed treatment was
63.2% (Marcenes et al, 1999). Forsberg and Tedestam (1990) showed that 30% of
the injured deciduous teeth required some kind of treatment. The corresponding

Chapter One: Review of Literature 27

figure for the permanent dentition was 46%. While, Traebert et al (2006) reported
that only 27.6% of the cases was treated and restorations were the most common
treatment provided and the most common type of treatment needed.
Al-Hayali (1998) reported that the majority of the injured teeth needed no
treatment (78%), while least treatment needed was extraction (3%). In another
Iraqi study, only 15.7% of the traumatized teeth had received treatment, While,
34.6% of the cases had seek treatment after trauma occurrence and dental visit
option was more common after the first week following crown fracture (Al-
Kassab, 2005).

1.3.1.9 Parental Level of Education:

Discussing this subject is conflicting and differs from one study to another.
Cortes et al (2001) revealed that children from parents with higher levels of
education were 1.4 times more likely to present with dental trauma than children
from parents with lower levels of education. Odoi et al (2002) results showed that
children whose fathers had completed 16 or less years of education were highly
significantly less likely to have traumatic injuries than those with more than 16
years of schooling. While Al-Kassab (2005) reported that males and females
showed more dental trauma with parents having primary school certificate than
other types of education levels.
Marcenes et al (2001) reported that children from mothers with higher
schooling experienced more dental injuries than those from mothers with lower
schooling, (68.2%) and (56.6%), respectively. But father's level of education,
parents' employment status and family income were not statistically significantly
associated with dental injuries. In other studies, no association was found between
socio-economic measures and dental trauma (Marcenes et al, 2000; Nicolau et al,
2001; Hamdan and Rajab, 2003; Traebert et al, 2004).

Chapter One: Review of Literature 28

1.4 Management of Dental Trauma:
Dental injuries could have improved outcomes if the public were aware of
the first-aid measures and the need to seek immediate treatment (Sae-Lim et al,
1999; Saroglu and Sonmez, 2002). Because optimal treatment results following
immediate assessment and care, dentists have an ethical obligation to ensure that
appropriate emergent dental care is available at all times. Assessment includes a
thorough history, visual and radiographic examinations, and additional tests such
as palpation, percussion, and evaluation of tooth mobility are necessary (Welbury,
2001; Andreasen et al, 2002).
The following dental and medical history lines are necessary for good
evaluation and management:
1. When did the injury occur? The time interval between injury and treatment
significantly influences the prognosis of avulsions, luxations, crown fractures
with or without pulpal exposures, and dentoalveolar fractures.
2. Where did the injury occur? May indicate the need for tetanus prophylaxis.
3. Lost teeth /fragments? If a tooth or fractured piece cannot be accounted for
when there has been a history of loss of consciousness then a chest radiograph
should be obtained to exclude its inhalation.
4. Concussion, headache, vomiting, or amnesia? Brain damage must be excluded
and referral to a hospital for further investigation organized.
5. Congenital heart diseases, bleeding disorders and drug allergies may require
alternative approaches (Welbury, 2001).
Examinations must start extraorally for lacerations and hemorrhage of the
extraoral structures and extended to include intraoral structures for swelling of the
oral mucosa and gingiva, abnormalities of occlusion, tooth displacement, fractured
crowns or cracks in the enamel. Degree of mobility, color of the tooth, reaction to
percussion and thermal or electrical sensitivity tests and radiographic images are
all important diagnostic measures for traumatized tooth (Andreasen, 1999). All
patients with traumatized teeth ultimately need follow-up with a dentist for
complete diagnosis and long term care. Long-term sequelae can include pulp death,
Chapter One: Review of Literature 29
root resorption, and displacement or developmental defects of permanent tooth
successors (Douglass and Douglass, 2003).
The most accident-prone time in the primary dentition is between 2 and 4
years of age. Realistically, this means that few restorative procedures will be pos-
sible, and in the majority of cases the decision is between extraction or mainte-
nance without performing extensive treatment. A primary incisor should always be
removed if its maintenance will jeopardize the developing tooth bud. A
traumatized primary tooth that is retained should be assessed regularly for clinical
and radiographic signs of pulpal or periodontal complications. Most traumatized
permanent teeth can be treated successfully (Welbury, 2001).
Fractures limited to the enamel and small amounts of dentine that are not
sensitive may not require immediate treatment but should be checked by a dentist.
Fractures exposing the pulp are often painful, and patients with this condition
require timely referral to a dentist. Tooth fragments should be kept hydrated as
they could possibly be reattached. Definitive treatment may involve root canal
therapy or extraction. Fractures of the root usually require a radiograph for
detection, unless the tooth is particularly loose and the fracture occurred close to
the gingival margin. Treatment may involve root canal therapy, splinting, or
extraction, depending on the exact nature of the root fracture (Andreasen, 2000).
Teeth subjected to lateral or extrusive luxation have been displaced and are
loose. In the primary dentition, if the traumatized teeth are so loose that they are in
danger of being aspirated or if they interfere with normal occlusion, immediate
referral to a dentist for extraction is required. Luxated permanent teeth require
repositioning, splinting, or root canal therapy, along with long term follow-up. Any
luxated tooth that interferes with normal occlusion requires immediate dental
evaluation and treatment to avoid pain and further complications. Teeth subject to
intrusive luxation have been intruded into the alveolar bone, which may occur to
the point that the teeth are not visible and dental referral is required for monitoring
or treatment to promote re-eruption (surgical or orthodontic), often coupled with
root canal therapy (Andreasen, 1999; McTigue, 2000).

Chapter One: Review of Literature 30

 Avulsed teeth are a true dental emergency. Avulsed primary teeth should not
be replanted because of the potential for subsequent damage to developing
permanent tooth germs and pulpal necrosis is a frequent event (McTigue,1999;
Flores, 2002). In the case of permanent teeth, immediate on-scene reimplantation is
the preferred method of treatment. Prognosis in the permanent dentition is
primarily dependent upon formation of root development and extraoral dry time
(Flores et al, 2001). The tooth has the best prognosis if replanted immediately. If
the tooth cannot be replanted within 5 minutes, it should be stored in a medium
that will help maintain vitality of the periodontal ligament fibers. Transportation
media for avulsed teeth include (in order of preference): Viaspan; Hanks Balanced
Salt Solution (tissue culture medium); cold milk; saliva (buccal vestibule);
physiologic saline; or water. If the tooth is visibly contaminated, it should be
gently rinsed in cold running tap water and then reimplanted. Care should be taken
not to touch, rub, or clean the root, which could remove periodontal ligament fibers
and reduce the chance of successful reimplantation (Andreasen et al, 1995; Barrett
and Kenny, 1997).
If immediate on-scene reimplantation is not possible, the tooth should be
transported in the patients buccal sulcus, milk, or a specialized tooth transport
container to the dentists office. The tooth should then be immediately reimplanted
and secured in place by a splint. If rinsing is required, normal saline should be
used, and any clot present in the socket should be flushed out before reimplantation
Antibiotic prophylaxis with penicillin should be prescribed, tetanus vaccine should
be administered if the patient has not received it in the past five years (Cameron
and Widmer, 1997; Welbury, 2001).

Chapter One: Review of Literature 31