Introductory Chapter: Etiology, Diagnostic, and Treatment Procedure at Traumatic Cases in Dentistry

*Serdar Gözler*

### **1. Introduction**

Dental trauma presents one of the most important situations where clinicians are called upon to make unscheduled diagnostic and treatment approaches in an area that is outside their routine experience. Guidelines have been outlined for management of numerous dental and medical conditions. Traumatic cases in dentistry are classified by many sources; however, the World Health Organization's (WHO) classification system is the most comprehensive system which allows for minimal subjective interpretations. The WHO traumatic classification system is built up according to the following situations [1]:


Most of the reported traumatic cases come from falls while children play [2]. At the present time, the dental trauma term must also be included for dental treatment sourced from traumatic cases. There are various invasive restorative dental treatment models in modern dentistry at the present time. For example, dental implant treatments, tissue repair purpose treatments, augmentations of maxillary sinuses,

 and full mouth ceramic restoration treatments are restorative treatments which have extreme trauma risks.

Traumatic cases need urgent diagnosis and quick treatment. However, according to a review article by Andrease et al., there are few studies showing a positive relationship between treatment delay and pulpal and periodontal ligament healing complications [3]. Practical and most economic reasons are fulfilled such as demand for acute treatment (i.e. within a few hours) or delayed (i.e. after the first 24 hours) in traumatic cases. But it is commonly accepted that all injuries should be treated within few hours, for the comfort of the patient and also to reduce wound healing complications.

 Another type of dental trauma is post-op developed traumatic cases which are based on bad occlusion usually. In many cases, sinus augmentation may be necessary; in this case, augmented sinus tissue must be supported by a biomaterial. Implants are placed when the biomaterial is set like a wall. The implants will bear occlusal forces after finishing implant-supported crowns. In some cases, biomaterial wall cannot bear the occlusal forces of implant-supported crowns and then collapses. That kind of problems is related to premature contact originated occlusal trauma. Traumatic occlusion is the most important reason for the breaking of the restorations or collapse of the operating area under the pressure of high occlusal load. Early occlusal contacts force the area with all cumulative occlusal pressure of the jaws. There may not be a problem if there is an adequate thickness set at the sinus augmentation. But in some cases, under the high occlusal forces, the biomaterial wall cannot bear the load and collapses consequently. Sometimes, sinus wall tears and the implant is mobilized to the far side of the sinus. The first action must take out the dislocated implant from the exposed sinus and repair the sinus wall. Generally, the accepted protocol is to wait after repair of the sinus area and then continue the implant treatment again [4, 5]. There are various approaches for the planning of dental implants: the number of implants, their locations, inclinations, quality of supporting bone, etc. In its wider sense, this includes considerations of multiple inter-related factors of ensuring adequate bone support, implant location number, length, distribution, and inclination, splinting, vertical dimension esthetics, occlusal schemes, and more [6]. Every different alternative of the planning of implant treatment will have a different effect on implant-supported restoration. The difference is related to the occlusal scheme of the prosthetic restoration.

Dentists must take their decisions according to their past experiences because the patients in avulsion are rare except children patients and emergency patients [7]. Additionally, clinicians must trust the preparation guidelines for trauma standards and the protocols stated before.

The protocols are set before but they have not tested for prospectively longitudinal studies in human. However, all protocols are set before and have found a strong place for routine applications clinically.

Periodontal wound healing protocols must be taken specially and must be based on biological reasons.

Permanent teeth's avulsions are the most serious of all dental traumatic cases. The prognosis of the treatment depends on the time taken at the place of accident or the time immediately after the avulsion [7]. Appropriate emergency management and treatment plan are important for a good prognosis. Guidelines are usually useful for delivering the best treatment possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions.

*Introductory Chapter: Etiology, Diagnostic, and Treatment Procedure at Traumatic Cases… DOI: http://dx.doi.org/10.5772/intechopen.86630* 

 Unlike deciduous teeth, permanent teeth rarely undergo root resorption. Even in the presence of periodontal and radicular inflammation, resorption will occur primarily on the support bone side of the attachment apparatus and the root will be resistant to it [8].

Facial trauma that results in fractured, displaced, or lost teeth (deciduous or permanent) can have significant negative functional, esthetic, and psychological effects on children. Clinicians should collaborate to educate the children and parents about the prevention and treatment of traumatic injuries to the oral and maxillofacial area.

#### **2. Diagnosis and treatment procedures according to the types of the traumatic cases**

#### **2.1 Radiographic examination**

Several radiographic images must be taken from every patient in different angles, but the final decision is up to the clinician [9].

The following are suggested:


Cone-beam computerized tomography is extremely useful at this stage. It can be used for radiographic examination in detail of root fractures, mobility of teeth, periodontal status, and peripheral destructions of teeth. The CBT Radiographic System may not be available in every clinic; it may not be used routinely, but advantages of the system cannot be compared with those of conventional systems. Information for dental application of CBT is documented very well in the scientific literature.

**Figure 1.**  *Nonrigid splints can be used for stabilization of mobilized and fractured teeth.* 

#### **2.2 Clinical examination, basic principles, and suggestions**

There are many protocols and approaches to the clinical examination. They are very well classified and documented in current textbooks for assessment of TDIs [1].

#### **2.3 Fixation with splints and their using period**

According to the recent researches, using short-term nonrigid splints for treatment of luxated, fractured, and avulsed teeth is supported (**Figure 1**). Basically, splints are essentials for the patient's comfort and improvement of functions, and they are useful to maintain the location and correct position of teeth [9–11].

#### **2.4 Medical treatment, antibiotics**

 There is no strong evidence for using systemic antibiotics for traumatic cases, luxation management, and coverage improvement of root fractures of teeth. This option is not mandatory and it is up to the dentist's own decision according to the past experience. Root fractures and related injures of teeth and soft tissue may need surgical intervention. Use of antibiotic option is harmonized to the surgical operations and especially it may be useful for the soft tissue healing procedure [12, 7]. Soft tissue injuries, treatment methods, and healing procedure information are neither comprehensive nor detailed information is found in textbooks, the scientific literature, and, most recently, the Dental Trauma Guide (DTG) that can be accessed on http://www.dentaltraumaguide.org. Additionally, the DTG, also available on the IADT's web page http://www.iadt-dentaltrauma.org, provides a visual and animated documentation of treatment procedures as well as estimations of prognosis for the various TDIs [13].

#### **2.5 Use of antibiotics**

There is no strong evidence for using systemic antibiotics for traumatic cases, luxation management, and coverage improvement of root fractures of teeth. This option is not mandatory and it is up to the dentist's own decision according to the past experience. Root fractures and related injures of teeth and soft tissue may need surgical intervention. Use of antibiotic option is harmonized to the surgical operations and especially it may be useful for soft the tissue healing procedure [14, 15, 2, 16].

#### **2.6 Sensitivity tests**

Sensitivity tests (cold test and electrical pulp test) are necessary for improving the pulp condition. Especially in an emergency atmosphere of a traumatic condition, revealing of pulp condition is one of the important attempts for treatment steps. Therefore, at least two signs and symptoms are necessary to make the diagnosis of necrotic pulp. Regular follow-up controls are required to make a pulpal diagnosis.

#### **2.7 Vitality of permanent teeth**

The basic principle is that maximum endeavor should be made for the protection of pulp vitality in a permanent tooth improving root development. Loss of a tooth in the period of childhood will produce occlusal source many complications. The immature permanent tooth can recover easily after exposing the pulp in traumatic

tooth/root fractures. In traumatic cases, root canal treatments are the most reasonable treatment for maintaining root development [8]. Additionally, emergency treatment of traumatized teeth can accelerate healing of the teeth.

#### **2.8 Traumatic occlusion**

 As a dental practitioner, we may cause occlusal trauma. We change the occlusal surfaces of teeth when we make functional and esthetical restorations in clinical practice. Usually, natural teeth have adapted and shaped occlusion in the developmental period of humans, especially the development of the craniofacial area [17]. Muscles, bones, and teeth must be in full harmony. But sometimes, they may not be in accordance with accepted rules or standards, especially anatomically. The neural system also adapts to that inappropriate structure and there does not exist any high neuronal impulse in the neural system that may cause excessive contraction of masticatory muscles [18]. The dentist may change this complex, improper but harmonic structure. Dental treatment procedures may disrupt this harmonic relationship when we make composite restoration, orthodontic treatment, prosthetic, and/or implant restoration. In order to avoid traumatic occlusion, occlusal compliance in dental restorations should be at the highest possible level.

Occlusal trauma may be spotted in the following situations:


The main reason for the occlusal trauma is premature contact in the occlusion. Every dentist must be able to manage premature contacts in dental treatments.

Occlusal trauma is one of the most common problems of dental treatment. Every dentist must be extremely careful about avoiding dental premature contacts.

 Trauma itself is not a disturbance, trauma is a result of an event. *Trauma is the damage of tissue and/or organs.* Trauma and its consequences may be acute or chronic. The acute situation is the result of the quick reflex response of the neuromuscular system to the premature contacts; however, the chronic situation may be developed within days, weeks, or years. The perception of the occlusal irregularity and a reaction to that problem is managed by the central nervous system (CNS). During human life, the main function of the masticatory muscles is to break food down into pieces small enough to be swallowed. CNS is like a protection mechanism of the stomatognathic system in that function. These are strong muscles that generate very large forces across in very short distances and apply them via rigid teeth. Such large forces can easily damage the teeth and their supporting tissues, tongue, cheeks, and the joints unless they are controlled precisely and effectively [3]. If the trauma is a system for protection of the stomatognathic structures, pain is the alarm ring bell of that system.

One of the biggest problems of prosthetic restorations is occlusal premature contacts. Early occlusal contacts cause the imbalance of dentures and it may

fracture the ceramic restorations. Unbalanced dentures are the reason for occlusal trauma and they may cause irritation on soft tissue and then tissue deteriorations consequently (**Figure 2**).

Occlusal premature contacts are effective on the way from the first contact to the maximum intercuspal position (MIP). It is not easy to detect premature contact at developing occlusion (**Figure 3**).

#### **Figure 2.**  *Occlusal trauma caused by an upper denture.*

#### **Figure 3.**

*Occlusal trauma: premature contact is affected on the way before of the way of MIP (maximum intercuspal position) peak point.* 

*Introductory Chapter: Etiology, Diagnostic, and Treatment Procedure at Traumatic Cases… DOI: http://dx.doi.org/10.5772/intechopen.86630* 

#### **Figure 4.**

*Premature contacts can be described easily by computerized occlusal analyzing system. Occlusal papers or similar methods can not much help for finding premature contact.* 

**Figure 5.**  *Cervical area of a tooth has been destroyed under the traumatic occlusion.* 

#### *Trauma in Dentistry*

The best method is computerized occlusal analyzing system for detecting the traumatic premature contact (**Figure 4**).

Abfractions are the reason for the wrong linear inclination of teeth and the tooth cervical area is damaged because of those kinds of problems of occlusal trauma (**Figure 5**).

Sometimes, the cervical area at the labial surface of the tooth is abraded in time because of the direction of occlusal force. If the teeth are covered by ceramic crown restoration, abrasion of teeth continues inside the ceramic restoration. Restorations are not protective against the abrasion (**Figure 6**). The only way to stop the abrasion is the occlusal adjustment of the restoration.

#### **Figure 6.**

*Abfraction continues under the restorations. Crown restorations cannot protect the teeth from traumatic occlusal forces.* 

**Figure 7.**  *Ceramic restorations have been broken under the traumatic occlusal strokes.* 

*Introductory Chapter: Etiology, Diagnostic, and Treatment Procedure at Traumatic Cases… DOI: http://dx.doi.org/10.5772/intechopen.86630* 

**Figure 8.** 

*(a–c) Implant selection, their locations, and surgical steps are almost perfect; (a) everything seems normal when controlling with articulating paper, (b) but the patient is never relaxed with his new restorations. The problem can be detected when examining restoration with computerized occlusal analysis technic: there is severe premature contact detected on the right second molar area (c). The patient relaxed just after occlusal adjustment (c).* 

 The ceramic materials are often used in restorative treatments. Premature contacts on the ceramic restorations must be eliminated; otherwise, periodontal receptors will never stop sending neuronal impulse and the muscles will never be relaxed. In this case, ceramic restoration has been broken because of the high occlusal pressure of premature contacts (**Figure 7**).

The abrasion effect of occlusal trauma is much more dramatically developed in the cases of implant prosthesis because implant restorations have no resilient features and the force transmits directly to the bone without resistance of any force breaker system like periodontal ligaments of natural teeth. In an implant-supported prosthesis, if occlusal equilibration is not made, the patient can never be relaxed. In **Figure 8a** and **b**, implant planning and surgery phase is perfect and the treatment with a full arch ceramic restoration is also finished, but the patient is never relaxed with his new restorations. The problem can be detected when examining restoration with computerized occlusal analysis technic: there is severe premature contact detected on the right second molar area. The patient relaxed just after an occlusal adjustment procedure (**Figure 8c**).

#### **3. Conclusion**

 The most exposed group to dental trauma is young adults and children. Fractures of the upper part of the teeth and luxations are the most frequent cases. For a healthy result, the most important approach is the proper diagnosis and then proper treatment consequently.. This action plan is not only for tooth level, but is also a proper approach for other type traumatic injuries; the guidelines which have been developed and set by "The International Association of Dental Traumatology (IADT)" are important supportive materials for the clinicians. There are many specialists and researchers on "Dental Traumatology" who added important and useful suggestions.

In some cases, the collected data from traumatic injury may not be clear and precise. In those cases, clinicians can use the basic and agreed of opinions of IADT board specialists. Suggestions and opinions for unexpected situations are also developed by the IDTA members.

There are various guidelines for any kind of levels of urgent and long-term traumatic cases which are prepared and set by TDIs.

*Trauma in Dentistry* 

#### **Author details**

Serdar Gözler Prosthodontic Department of Dentistry Faculty, Istanbul Aydın University, Istanbul, Turkey

\*Address all correspondence to: serdargozler@aydin.edu.tr

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Introductory Chapter: Etiology, Diagnostic, and Treatment Procedure at Traumatic Cases… DOI: http://dx.doi.org/10.5772/intechopen.86630* 

#### **References**

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[2] Perez R, Berkowitz R, Mcllveen L, Forrester D. Dental trauma in children: A survey. Dental Traumatology. 1991;**7**(5):212-213. DOI: 10.1111/j.1600- 9657.1991.tb00438.x

[3] Andreasen JO, Gerds TA, Lauridsen E, Ahrensburg SS. Dental trauma guide a source of evidence-based treatment guidelines for dental trauma. Dental Traumatology. 2012;**28**:345-350

[4] Cotruţă AM, Mihăescu CS, Tănăsescu LA, Mărgărit R, Andrei OC. Analyzing the morphology and intensity of occlusal contacts in implant-prosthetic restorations using t-scan system. Romanian Journal of Morphology and Embryology. 2015;**56**(1):277-281

[5] Wong RCW, Tideman H, Kin L, Merkx MAW. Biomechanics of mandibular reconstruction: A review. International Journal of Oral and Maxillofacial Surgery. 2010;**39**(4):313- 319. DOI: 10.1016/j.ijom.2009.11.003

[6] Gross MD. Occlusion in implant dentistry. A review of the literature of prosthetic determinants and current concepts. Australian Dental Journal. 2008;**53**(Suppl. 1)

[7] Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dental Traumatology. 2007;**23**(3):130-136

[8] Trope M. Root resorption due to dental trauma. Endodontic Topics. 2002

[9] Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, et al. Guidelines for

the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Pediatric Dentistry. 2016;**38**(6):358-368

[10] Flores MT, Malmgren B, Andersson L, Andreasen JO, Bakland LK, Barnett F, et al. Guidelines for the management of traumatic dental injuries. III. Primary teeth. Dental Traumatology. 2007;**23**(4):196-202

[11] Von Arx T, Filippi A, Lussi A. Comparison of a new dental trauma splint device (TTS) with three commonly used splinting techniques. Dental Traumatology. 2001;**17**(6):266-274

[12] Lin S, Zuckerman O, Fuss Z, Ashkenazi M. New emphasis in the treatment of dental trauma: Avulsion and luxation. Dental Traumatology. 2007;**23**(5):297-303

[13] Berger TD, Kenny DJ, Casas MJ, Barrett EJ, Lawrence HP. Effects of severe dentoalveolar trauma on the quality-of-life of children and parents. Dental Traumatology. 2009;**25**(5):462-469. DOI: 10.1111/j.1600-9657.2009.00809.x

[14] Lee JY, Yanpiset K, Sigurdsson A, Vann WF. A case report of reattachment of fractured root fragment and resin-composite reinforcement in a compromised endodontically treated root. Dental Traumatology. 2001;**17**(5):227-230

 [15] Kargul B, Caglar E, Tanboga I. Dental trauma in Turkish children, Istanbul. Dental Traumatology. 2003;**19**(2):72-75. DOI: 10.1034/j.1600-9657.2003.00091.x

[16] Case I, De Rossi SS, Stern I, Sollecito TP, Fushima K, Gallo LM, et al. Dislocation of the. Journal of Prosthodontic Research.

1985;**25**(3):246-251. DOI: 10.1016/j. jfoodeng.2016.06.008

[17] Hattori Y, Satoh C, Kunieda T, Endoh R, Hisamatsu H, Watanabe M. Bite forces and their resultants during forceful intercuspal clenching in humans. Journal of Biomechanics. 2009;**42**(10):1533-1538

[18] Iwase M, Ohashi M, Tachibana H, Toyoshima T, Nagumo M. Bite force, occlusal contact area and masticatory efficiency before and after orthognathic surgical correction of mandibular prognathism. International Journal of Oral and Maxillofacial Surgery. 2006;**35**(12):1102-1107

Section 2 Implants

**17**

**Chapter 2**

**Abstract**

Dental Implants and Trauma

Implant dentistry treatment target to avoid any kind of edentulous state including tooth loss due to trauma. In the literature there are numerous case reports and few clinical studies documenting treatment options of post-trauma patients by dental implants. Principally there are some limitations of dental implant application related to the age and available bone volume of patients. Implant candidate should complete bone growth as the metallic implants do not follow bony development phases. Most often traumatic dental injuries occur in childhood and implant treatment should postponed. In this aspect the major problem associated with dental implant placement is the lack of adequate bone volumes at the future time of surgery as such cases receives traumatic dental injury in the early years and disuse atrophy occurs during waiting period. Future trends and strategies in dental traumatology in general and with special attention to dental implant applications are based on the education of population in terms of emergency treatments and urgent

**Keywords:** dental implant, trauma, implant placement, dental lasers, erbium laser,

Dental implant applications are wide spreading globally and in last three decades

it is the major attraction field for both clinicians and patients. Implant dentistry treatments target to avoid any kind of edentulous state including tooth loss due to trauma. Tooth loss after trauma could be related to traumatic dental injuries depending from violence, falls, traffic accidents, gunshots or to late consequences of trauma such as recurrent endodontic lesions, vertical root fractures, external or internal root resorptions and ankylosis which bring teeth to untreatable condition. Trauma-related tooth loss most often involve anterior maxillary teeth and generally is rehabilitated as single tooth implant replacement or several teeth are affected and rehabilitation is made as a solution of partially edentulous case but being in the anterior region with the rules of single-tooth replacement to preserve esthetics. Patient age constitute another aspect of post-trauma cases where accidents mainly happen in childhood period which is not favorable for dental implant applications due to incomplete bony growth. For the patients in development stage there should be followed special attention for future dental implant rehabilitation. Thus, care must be taken to find suitable treatment solutions in order to provide interim prosthetic treatment, to follow normal bone growth, avoid hard tissue atrophy and preserve alveolar bony dimensions for upcoming implant surgery in the late adolescent age. In the present chapter post-trauma applications of dental implants are

discussed and possible treatment strategies are evaluated.

*Tosun Tosun and Koray Meltem*

transport of patients to the clinics.

traumatic injuries, iatrogenic factors

**1. Introduction**

## **Chapter 2**  Dental Implants and Trauma

*Tosun Tosun and Koray Meltem* 

### **Abstract**

Implant dentistry treatment target to avoid any kind of edentulous state including tooth loss due to trauma. In the literature there are numerous case reports and few clinical studies documenting treatment options of post-trauma patients by dental implants. Principally there are some limitations of dental implant application related to the age and available bone volume of patients. Implant candidate should complete bone growth as the metallic implants do not follow bony development phases. Most often traumatic dental injuries occur in childhood and implant treatment should postponed. In this aspect the major problem associated with dental implant placement is the lack of adequate bone volumes at the future time of surgery as such cases receives traumatic dental injury in the early years and disuse atrophy occurs during waiting period. Future trends and strategies in dental traumatology in general and with special attention to dental implant applications are based on the education of population in terms of emergency treatments and urgent transport of patients to the clinics.

**Keywords:** dental implant, trauma, implant placement, dental lasers, erbium laser, traumatic injuries, iatrogenic factors

#### **1. Introduction**

Dental implant applications are wide spreading globally and in last three decades it is the major attraction field for both clinicians and patients. Implant dentistry treatments target to avoid any kind of edentulous state including tooth loss due to trauma. Tooth loss after trauma could be related to traumatic dental injuries depending from violence, falls, traffic accidents, gunshots or to late consequences of trauma such as recurrent endodontic lesions, vertical root fractures, external or internal root resorptions and ankylosis which bring teeth to untreatable condition. Trauma-related tooth loss most often involve anterior maxillary teeth and generally is rehabilitated as single tooth implant replacement or several teeth are affected and rehabilitation is made as a solution of partially edentulous case but being in the anterior region with the rules of single-tooth replacement to preserve esthetics. Patient age constitute another aspect of post-trauma cases where accidents mainly happen in childhood period which is not favorable for dental implant applications due to incomplete bony growth. For the patients in development stage there should be followed special attention for future dental implant rehabilitation. Thus, care must be taken to find suitable treatment solutions in order to provide interim prosthetic treatment, to follow normal bone growth, avoid hard tissue atrophy and preserve alveolar bony dimensions for upcoming implant surgery in the late adolescent age. In the present chapter post-trauma applications of dental implants are discussed and possible treatment strategies are evaluated.

#### **2. Etiology, prevalence of traumatic dental injuries and implant dentistry**

 Traumatic dental injuries (TDIs) have different frequencies worldwide, but always low prevalence among communities [1–6]. Etiologic factors of TDIs are various from country to country and with age groups [7]. Globally the most common etiology of TDI in men is violence. For women there are three most common injury factors: violence, falls and traffic injuries [6, 8–10]. Ballistic injuries (gunshots) form a severe type of traumatic maxillofacial injury [11, 12] and can be classified in between the etiologic factors of TDIs. TDI studies most often cover children and adolescents. There are few studies involving adults [1, 6, 13, 14]. Studies show that the TDIs affect mainly anterior maxilla and especially central incisors [3, 8, 15–17]. Generally teeth involved by TDIs are lost in the long run and subsequently this anatomic lack may result in significant esthetic and functional problems [6].

The consensus statements of International Association of Dental Traumatology (IADT) propose to delineate approaches for the immediate or urgent care for management of primary and permanent teeth injuries [9, 10, 18]. The emergency treatment after TDIs is highly important for the future management of dental structures [15, 16]. Although attempts is to preserve natural dentition and despite best efforts at retaining and maintaining trauma-compromised teeth, studies show that in the long run affected teeth are loose and replaced by dental implants [19]. Studies and case reports are shown that implant placement after TDIs is a suitable treatment of choice [20–22].

In the epidemiological study, Ugolini et al. [1] determined the prevalence, types, and characteristics of occupational (work-related) TDIs in a large working community where among 212 traumatized teeth, upper incisors took the first place with 67.5%, lower incisors showed 17.5% incidence, upper canines were only 3.3%, lower canines with 1.9% were less than uppers, and bicuspids and molars had 9.9% prevalence. In conclusion occupational TDIs exhibit a low prevalence and the most frequent dental injury type were fractures. Possible etiologic risk factors for occupational TDIs were mentioned to be the age, gender and existence of previous dental treatments.

Rozi et al. [15] studied complications of permanents teeth after TDIs in 50 children [age range 7–18 years (mean, 11 years); 32 (64%) males and 18 (36%) females]. According to the findings of this study, TDIs mostly involved the maxillary central incisors by 90% incidence. Uncomplicated enamel and dentin fracture without pulp exposure was the most common type of TDI with 62%. Only 50% of the cases showed luxation type injuries. The urgent and proper timing in treatment was underlined and it was considered to be the primary important strategy to increase the prognosis.

 Zaleckiene et al. [2] reviewed etiology, prevalence and possible outcomes of dental trauma. TDIs prevalence was found to be different among countries. TDIs are more prevalent in permanent than in primary dentition. Treatment strategies are directed to eliminate undesired consequences, but TDIs in the young patient is often complicated and can continue during the rest of his/her life.

 Atabek et al. [16] examined epidemiological and dental data from TDIs to primary and permanent teeth during the period from 2005 to 2010. The study included 120 girls (35.3%) and 220 boys (64.7%) with an average age of 9 years. The maxillary central incisors were most commonly affected teeth with a prevalence of 66.24%. The main cause of TDIs was found to be the falls by 70.1% incidence. In primary dentition highest percentage of injuries were subluxations with 36.4% rate. In permanent

#### *Dental Implants and Trauma DOI: http://dx.doi.org/10.5772/intechopen.81202*

dentition, uncomplicated crown fractures by 44.9% incidence were most frequent type of injury. In conclusion they stated that the prognosis of dental trauma cases varies depending on the time elapsed after the trauma before treatment started.

 Zengin et al. [3] evaluated TDIs recorded using the World Health Organization classification modified by Andreasen et al. As the prevalence in a group of 5800 patient 255 had TDI (4.4%). TDIs were related mostly to the age group of 11–20 years. As gender distribution most affected were males (153 cases) and females got less injuries (102 cases). The main cause of traumatic injury was related to falls with 68.2% incidence, and generally trauma was taken place during outdoor activities by 56.1% prevalence. Upper central incisors took first place among the most frequently injured teeth with primary teeth injuries of 64.5% and permanent teeth injuries of 72.5%. Uncomplicated crown fracture was the most frequent type of TDI seen in both primary dentition with a percentage of 63% and permanent dentition with 47% incidence. In the population of the study, TDIs prevalence was considered to be low.

Unal et al. [17] through a retrospective study identified TDIs of 591 children (range 0–14 years, average age: 10.79 ± 2.06) referred to university hospital between years 2007 and 2012 in Sivas, Turkey. TDIs mostly occurred in the children of 12–14 years age group with 14% incidence. Dento-enamel fractures was the most common type of injury in primary teeth with 58% prevalence. Complicated crown fractures were most frequent type of TDI in permanent teeth with an incidence of 39%. The major etiologic factor of TDI was falls having 30% prevalence. The upper central incisors (71%) were the mostly affected teeth in both primary and permanent teeth. Only 63 children (11%) were referred to the clinic less than 30 minutes after trauma. The findings of this study showed that initial treatment after dental trauma should be performed immediately.

 Kovacs et al. [4] in a retrospective study assessed the prevalence of TDIs in deciduous and permanent teeth among children and teenagers in Targu Mures city of Romania, between 2003 and 2011. The prevalence of TDIs was 24.5%. In the primary dentition the most frequent type of TDI was lateral incisor's luxation. In the permanent dentition, dento-enamel fractures without the exposure of the dental pulp were the most common type of TDI.

Hasan et al. [5] investigated a total of 500 of preschool children in Kuwait. The study reported TDIs etiologic factors, frequency, trauma type classification, injury localization and involved teeth numbers, treatment performed after injury. Among 500 children 56 subject got TDI involving 68 primary teeth with a prevalence of 11.2%. Fifty-three of 56 children got TDIs due to falls (94.6%). Upper primary central incisor was the most traumatized tooth with 55 units and 80.8% frequency. TDIs prevalence among such population was considered to be low.

 Glendor [23] reviewed 12-years international literature regarding TDI to point the prevalence and incidence. TDIs were found to be a global phenomenon all over the world with variations in prevalence, etiologic factors, gender and localization of involved teeth. Across the world with slight differences from country to country, approximately 1/3 of preschool children got TDI in the primary dentition. Regarding TDI to the permanent dentition it could be concluded that although few variations among countries, about 1/4 of school children and almost 1/3 of adults received trauma.

 According to Locker [13], 15.5% of the Canadians with age between 18 and 50 years old, living in the province of Ontario reported a history of injury to the mouth and teeth. The survey of this study involved 2001 adults who called by random digit dialing and answered to a questionnaire via telephone. Among the people who got TDI, 2/3 declared that injuries happened before the age of 18 years and 1/3 after adolescence.

#### *Trauma in Dentistry*

Kaste et al. [14] reported findings of 7707 patients. According to Kaste's study, approximately one-quarter (24.9%) of the US population aged 6–50 years had at least one traumatized teeth.

Zerman and Cavalleri [6] examined 2798 patients having 6–21 years old age, with a follow-up period of 5-years in Verona, Italy. Among abovementioned population 178 were TDI cases, 131 males and 47 females, having 326 traumatized incisor teeth with a prevalence of 7.3%. Most frequent causes of injuries were falls and traffic accidents. A very large number of dental injuries occurred to children aged between 6 and 13 years. Most injuries involved two teeth. About 80% of the teeth were maxillary central incisors.

#### **3. Dental implant treatment in post-traumatic dento-alveolar defects**

 In the literature there are numerous case reports and few clinical studies documenting treatment options of post-trauma patients by dental implants [24–29]. In those reports and studies cases underwent to trauma due to violence, falls, traffic injuries, gunshots which were later rehabilitated by use of dental implants are described in details. Treatment approaches reported are various as the cases exhibit different conditions related to the type of trauma, anatomy and age. Principally there are some limitations of dental implant application related to the age and available bone volume of patients. One of the main criteria for dental implant placement is the presence of complete bone growth as the metallic implants do not follow bony development phases [30–34]. Most often TDIs occur in childhood and implant treatment should postponed as mentioned [31]. Thus, the children who receives TDIs should wear removable or adhesive prosthesis until their skeleton mature. In this aspect the major problem associated with dental implant placement is the lack of adequate bone volumes at the future time of surgery as such cases receives TDI in the early years and disuse atrophy occurs during waiting period [21]. Maxillary central incisors area which is commonly affected zone by TDIs is most apparent site of the dentition and requires proper dimensions and proportions to establish esthetic and require complex treatment solutions such as bone grafting with autogenous or synthetic graft materials, guided bone regeneration applications; immediate, early or delayed implant placement methods (**Figures 1**–**7**).

 Nicoli et al. [24] wrote records of a multidisciplinary treatment made in a gunshot injury case. Patient got severe anatomic defect in the mandible which was rehabilitated by use of an implant-supported fixed-removable dental prosthesis. In order to restore intermaxillary relation an immediately loaded provisional lower overdenture and upper removable prosthesis were delivered.

#### **Figure 1.**

*Traffic accident case: central incisor number 21 was lost due to a traffic incident trauma; bone volüme was reduced in the buccal side and soft tissue was injured by a vertical laceration in the medial part of keratinized mucosa.* 

#### *Dental Implants and Trauma DOI: http://dx.doi.org/10.5772/intechopen.81202*

 Following interim prosthesis installations, in order to increase the maxillary bone volume, nasal floor elevation and maxillary sinus lifting operations were performed. Subsequently definitive implant-supported fixed-removable prostheses were delivered in both arches to improve masticatory function and esthetics.

Fındık et al. [25] presented rehabilitation of a wide mandibular traumatic defect due to a work-related accident with iliac free flap, distraction osteogenesis, and dental implants. Distraction osteogenesis, free flap and dental implant placements were considered as an effective and esthetic treatment option for rehabilitation of post-trauma defects.

 Balla et al. [26] described 5-year follow-up of surgical and prosthetic reconstruction of a gunshot injury using dental implants which was found to be

**Figure 2.** 

*Titanium/zirconia alloy dental implant (Bone Level SLA, Straumann AG, Swiss) was placed.* 

**Figure 3.** 

*Titanium mesh was placed on the buccal side and secured into the implant by cover screw.* 

#### **Figure 4.**

*After 6 weeks of healing period a mucosa former abutment was placed. The laceratio formed after traffic accident still persist on the buccal mucosa.* 

#### *Trauma in Dentistry*

#### **Figure 5.**

*Intraoral appearance of implant supported lithium disilicate single crown placed on top of custon zirconia abutment.* 

**Figure 6.**  *OPG after crown placement.* 

#### **Figure 7.**

*Appearance after prosthesis delivery: note hypertrophic sequelae of upper left lip due to traffic accident.* 

effective treatment modality in restoring a patient to near normal function and esthetics. According to this study, maxillofacial injuries made by gunshot create serious esthetic, functional, and psychological consequences. Disabling characteristic of such severe maxillofacial ballistic defects brings the need of challenging extensive reconstructive multiple surgeries and competitive prosthetic rehabilitation phases.

 Jain and Baliga [27] described two cases with maxillofacial trauma and had undergone open reduction and internal fixation where implant placement was done for upper anterior teeth.

Sharma and Swamy [28] reported a gunshot case who lost six teeth in maxilla and was rehabilitated by rotated flap, bone grafts and three dental implants supporting a FPD.

#### *Dental Implants and Trauma DOI: http://dx.doi.org/10.5772/intechopen.81202*

 Wang et al. [29] mentioned the treatment a 17-year-old boy having maxillofacial ballistic defects. They described multiple techniques for restoration of facial morphology and function. Multiple examinations and surgical procedures including osteomyocutaneous and muscular flaps in combination with dental implants were used to restore facial morphology, functions of mastication and articulation.

 Generally implant placement is planned after orthodontic treatment to gain adequate space [21]. But there are exceptions reported depending from the needs and anatomy of individuals such as Kuo et al. [35] who reported a case where after a traumatic loss of upper incisor an implant was placed and subsequent orthodontic treatment was performed.

Kulkarni et al. [36] reported ballistic injury of a 24-year-old man. Maxillofacial deficiency was restored with autogenous iliac bone graft. Following 3 months of healing dental implants were placed. After osseointegration period of 5 months fixedremovable hybrid prosthesis was installed. At the end of third year of hybrid prosthesis usage, it was renewed by a porcelain fused to metal bridge. Follow-up on radiographies showed that the crestal bone levels around implants were stable. Kulkarni et al. [36] stated that the rehabilitation of gunshot injuries is expanded within time and needs several interventions to obtain functional and esthetics requirements.

Seymour et al. [37] mentioned the need of team approach in the rehabilitation severe trauma cases and underlined the importance of communication between general practitioners and specialist especially in the complex dental implant treatments.

Chesterman et al. [38] described guidelines regarding the replacement of single teeth lost due to trauma with implant supported restorations. The protocol proposed includes: evaluation of tooth replacement methods; planning for tooth loss and provision of an implant supported restoration; planning of an implant supported restoration.

Alani et al. [39] stated that with advances in both adhesive technologies and implant dentistry, there are a variety of options for the restoration of edentulism subsequent to TDIs.

 Pae et al. [22] described a panfacial fracture case who was managed with a mandibular implant-supported fixed-removable and a maxillary partial removable prosthesis where due to the lack of intraoral landmarks, overall facial anatomic landmarks were used to restore the oral cavity.

Kamoi [40] reported treatment history of a 44-year-old woman who had severe injuries due to traffic accident. The patient got maxillofacial soft tissue lacerations followed by hard tissue fractures, several teeth loss associated with alveolar bone resorption. Several facial reconstructions were made by plastic surgeons. To replace missing upper teeth a sinus grafting procedure was performed by use of a rib bone anchorage and simultaneous placement of five dental implants. After 11 months of healing period, upper overdenture and a mandibular PFM's were fabricated. The outcome of the treatment was found to be satisfactory.

Robinson and Cunningham [41] described the oral rehabilitation of an adult male who suffered severe dentoalveolar trauma as a result of a motor vehicle accident. After extraction of fractured roots, dental implants were placed. Following certain healing period for osseointegration, PFM crowns and FPD's were installed. In a 3-year follow-up period, the outcomes of the treatment were considered to be successful regarding patient's esthetic and functional expectations.

 Schneider et al. [42] reported the surgical and prosthodontic rehabilitation of a patient traumatized by a self-inflicted gunshot wound to the mandible which required rehabilitation with a free fibula microvascular graft, single stage dental implant placement, and rehabilitation with CAD/CAM and laser assembled prosthetic components.

 Nissan et al. [43] evaluated the outcome of dental implants placed in the posttraumatic anterior maxilla after ridge augmentation with cancellous freeze-dried block bone allografts. After 6 months of healing, implants were placed. The study group was composed of 20 consecutive patients with a mean age of 25 ± 7 years, received 31 implants, 12 of them were immediately restored. Graft and implant survival rates were 92.8 and 96.8%, respectively. There were no changes in bone to implant contact (BIC) levels. The authors considered predictable the usage of cancellous block allografts in the reconstruction of post-traumatic defects of anterior maxilla.

Yamano et al. [44] gave treatment history of a 15-year-old male patient who had a snowmobile accident. Patient got maxillofacial defects and fractures in mid-face and mandible. A multidisciplinary rehabilitation was performed to restore function and esthetics. Treatments involved usage of autologous corticocancellous bone grafts, fixture placement and implant-supported prosthesis fabrication.

A ballistic maxillofacial injury case and her treatment modality was described by Torabi et al. [45] The patient received trauma in maxilla, mandible and nasal areas with heavy problems in her esthetics and functions. Dental implants were used in conjunction with natural abutments to restore dentition.

 Bird and Veeranki [46] reported a maxillofacial ballistic injury case rehabilitated with iliac crest bone graft, dental implants, and an economical acrylic resin fixed prosthesis. A 3-year follow-up revealed positive treatment outcomes and it was concluded that although facial gunshots cause severe defects, they can be restored and rehabilitated by a multidisciplinary approach. They outlined the importance of and biomechanical considerations for implant positioning.

Kelly and Drago [12] described a patient who suffered significant trauma to the lower and mid-face secondary to a gunshot injury. The size and severity of the defects are in proportion with the functional and esthetic complications faced during the late phases of the treatment. Regardless to the amount of facial trauma, successful treatment can be performed by appropriate clinical and radiographic examinations and diagnosis followed with correct treatment strategies and applications strictly linked to surgical and prosthodontic principles.

 Gökçen-Röhlig et al. [47] described the rehabilitation of a patient with a mandibular defect caused by a gunshot wound who was treated with four osseointegrated implant-supported mandibular overdenture and maxillary removable prosthesis. Despite anatomic limitations, the patient's esthetic and functional demands were fulfilled.

Sándor and Carmichael [48] proposed to respect growth and delay implant reconstruction until the cessation of skeletal or alveolar growth.

 In the 2-year follow-up report of a traffic accident and traumatic injury happen to 16 years old male patient who was rehabilitated by autogenous graft and four dental implants, outcomes were found to be satisfactory and stable [49].

 Sipahi et al. [50] reported a self-inflicted gunshot maxillofacial defect case who was restored with dental implants and various prosthetic attachments. During short-term follow-up period no complications were occurred. The outcome of a fixed-removable implant-supported mandibular prosthesis and a maxillary obturator was considered successful in the management of a serious traumatic injury.

Clinical evaluation of a mandibular ballistic injury patient was described by Cakan et al. [51]. The patient was treated with cemented crowns for 2 maxillary implants and an implant-supported screw-retained fixed partial denture supported by eight mandibular implants. Although difficulties to properly position the implants because of inadequate bone volume, esthetic and functional demands of the patient were fulfilled.

Schwartz-Arad and Levin [20] examined a patient pool of 53 individuals having dental implants after traumatic injury history in the anterior maxilla. They found

#### *Dental Implants and Trauma DOI: http://dx.doi.org/10.5772/intechopen.81202*

 significantly lower complications in the group of patients which did not have inflammatory lesions in their history. Meanwhile patients who lost their teeth due to inflammatory lesions after traumatic injuries got statistically significant amount of complications and failures with dental implants. They underlined the necessity for scrupulous diagnosis of teeth and alveolar bone after a traumatic injury in order to reduce complications and advised individualized treatment planning for each case as the methodology is multidisciplinary.

 Schwartz-Arad et al. [21] mentioned the difficulties in the dental implant based rehabilitations in patients who got traumatic injuries in childhood where implant placement is contraindicated during growth period and on the other hand they need replacement of missing teeth and also preserve adequate jaw bone volume for future implant placement. Various treatment strategies were suggested until the end of growth and development. Among them, orthodontic extrusion of the root fragment and a temporary crown application technique in order to preserve alveolar bone, autogenous tooth transplantation, intentional extraction and immediate tooth replantation, distraction osteogenesis, and decoronation could be mentioned.

Five-year follow-up results of 42 single-tooth implant treatment in 34 traumarelated edentulous patients were evaluated by Andersson et al. [52]. In this patient pool the most frequently lost teeth were upper central incisors with an incidence of 75%. In the second place there were lateral incisors with 21% frequency. In growing patients, implant treatment was generally postponed until completion of development. Preservation of roots in the alveolar process seemed to maintain the bone volume enabling better conditions for later implant placement. According to the findings of this study, the functional and esthetic outcome of single-tooth implant treatment can be recommended for replacing tooth losses after trauma in the anterior region of the maxilla.

 Tipton [53] reported a case who had TDI due to an accident and rehabilitation protocol with a team approach for dental implant restoration. The outcome was considered excellent regarding the teamwork among the dentist, implant surgeon, and laboratory technician following traumatic injury of the dentition.

#### **4. Prerequisites for dental implant placement after trauma**

 Systemic conditions and history of the patient should be favorable to the surgery. In the medical history of the patient possible genetic, autoimmune and connective tissue diseases must be investigated in order to reduce risk factors [54]. In the history of patient presence of recent cerebrovascular disturbance and myocardial infarct, ongoing immunosuppressive [55] or chemotherapy, fibrous dysplasia [56–58], intravenous bisphosphonate therapies [59–64], uncontrolled diabetes [65–69], narcotic dependencies or psychiatric diseases form absolute contraindication for dental implant treatment [70]. In such conditions alternative prosthodontic treatments should be planned. Some form of diseases, treatments and drug therapies which affect metabolic activity of body and habits are considered to be relative contraindications as they reduce success and longevity of osseointegration. In the presence of any relative contraindication it must be evaluated the need of dental implant treatment for the patient and health conditions in the decision-making phase. Among relative contraindications there are past radiotherapies with irradiated jawbones [71–74], diabetes, autoimmune connective tissue diseases (rheumatoid arthritis [75–77], Sjögren's syndrome [78], Lupus Erythematosus [79], Papillon-Lefevre syndrome [80–82], Behcet disease, Myasthenia Gravis, Ectodermal Dysplasia [83–87], Skeleroderma [88–90]), calcium-phosphate metabolism disorders and endocrine diseases (osteoporosis, osteopenia, Paget disease, hyper and hypothyroidism, kidney nephritis, aldosteronism, Cushing syndrome), viral diseases (HIV, Hepatitis III), aggressive periodontitis, smoking, drug abuse, oral bisphosphonate usage, unstable psychological state. Other risk factors which should be evaluated during treatment planning are parafunctions-bruxism and facial dystonia [91].

 Animal model studies have shown that metallic implants do not change location in concordance with three-dimensional bony growth [92–95]. Dental implants do not follow bone development during growth period [34, 92–101]. Studies have shown that implants placed in the early ages remain in infra-occlusion by time [99]. For this reason as the consensus, implant treatment is made after confirming bony development period of patient by hand-wrist radiographies and comparisons in radiography-skeleton atlas [98, 100]. Ulnar sesamoid cartilage and middle finger's middle phalanx distal cartilage ossification rate is inspected and compared with images in skeleton atlas. For the minimal age of implant surgery decision instead of chronological age, skeletal age of patient is taken in consideration. Patients who are within the active bone growth period can receive removable prosthesis or adhesive prosthesis. In children adhesive prosthesis such as Maryland type are splinting teeth together and apply stationery anchorage against three-dimensional enlargement of jawbones during active bone growth. Growing patients should periodically controlled and adhesive prosthesis should modify in case of need. In future implant placement plans traumatized roots should be kept in place as space maintainers although their prognosis is poor. Slow orthodontic extrusion of traumatized hopeless roots is one of the bone guidance methods in order to create adequate hard tissue volume for upcoming dental implant rehabilitation [102].

 The first prerequisite in implant dentistry is the presence of adequate vital bone volume to entirely cover the implant body [103]. If trauma happens in childhood ending with tooth loose, patient should wait certain years until active bone growth completes before implant placement and during waiting period bone volume decrease in edentulous areas by disuse atrophy. In atrophic crests various augmentation method could be applied. The first choice of augmentation material is autogenous bone grafts. Autogenous bone graft blocks can be placed over recipient residual bone site and fixed by mini-screws, or 'Bone Lamina' technique which consist in splitting a bone block in thin layers and fix them onto the augmentation area by mini-screws as shields to create a certain volume and fill inside the shields with particulate autogenous or synthetic grafts. Autogenous bone grafts are always considered as the golden standard in augmentation procedures. Secondly osteoconductive ceramic alloplast (hydroxylapatite, tricalcium phosphate) or xenografts (bovine, mini-pig, single-hoofed) are preferred. Demineralized, demineralized freeze-dried or frozen homolog transplants although are osteoinductive they have non-predictable life-time and may not be adequate to complete osteogenesis phases in time scale. Other augmentation alternative is the usage of titanium grid-mesh (Ti-mesh) shields to obtain tent effect and fulfill them by particulated graft materials. Similarly, Guided Bone Regeneration (GBR) technique can be applied by use of resorbable or non-resorbable membranes alone or in conjunction with graft materials according to the defect size. Split-bone technique is suitable for crests thicker than 3 mm in buccopalatal section and mainly is adequate for pliable maxilla rather than less elastic mandible. Crestal bone is splinted in equal two pieces by micro-saws, piezoelectric inserts or Erbium Yttrium Aluminum Garnet (Er:YAG) laser until bypassing cortical bone. Once spongious bone is arrived special splitter osteotome inserts are placed into osteotomy site. To avoid unpredictable fractures vertical release osteotomies should be made in the extremities of the working field. Distraction osteogenesis is another technique well documented for bone augmentation. But distraction appliances are difficult to maintain for children in the interactive play age and could be further traumatized often.

#### *Dental Implants and Trauma DOI: http://dx.doi.org/10.5772/intechopen.81202*

 The choice of augmentation method depends on the defect size, volume, tridimensional shape of hard tissues and biotype of soft tissues. If the vertical dimension of the crest is normal but bucco-palatal width is missing GBR, Ti-mesh, Split-bone, onlay graft, Bone Lamina techniques could be used. When the vertical bone height is lost onlay grafting, Bone Lamina, distraction osteogenesis and Ti-mesh would be preferences. Soft tissue thickness establishes biotype of mucosa. Thin biotypes are difficult to manage as they are fragile and difficult elongate in order to achieve tension free flap. Flaps which cover wound should be overlay on grafted area without pressure in order to obtain normal blood supply. If there would be several tensions on the flap, vascular network will suffer and due to the lack of nutrition surgery can fail. Flap design gain certain importance to have profuse blood circulation. Flaps with larger base than free edge, possibly without vertical release incisions can maintain vascular network without interruption of capillary arteriae and vessels. Anatomic studies have shown that within the buccal and palatal mucosa, capillary networks do not constitute anastomosis on the top crestal region of maxilla and mandible [104]. Thus by mid-crestal incisions there is no interruption of vessels and this type of incision should be choice of preference. Mucosal flaps according to depth could be 'full-thickness' where epithelium, connective tissue and underlying periosteum are excited and elevated together; or 'split-thickness' where periosteum is left attached to the cortical bone to avoid blood supply interruption (because capillary arteriae network is situated within the periosteum and 70% nutrition of the cortical bone derives from periosteum), and to have elasticity of the flap (periosteum do not have elastic behavior). Thick biotype mucosa has an advantage in terms of elongation. To elongate a full-thickness flap the basal portion of it which is constituted by periosteum should be gently incited horizontally. In such manner the rigidity of the periosteum is alternated and underlying connective tissue portion would elongate easily as contains elastin fibers of collagen. Split-thickness flaps could be preferred only in thick biotype mucosa as the thin biotype is difficult to split and fragile.

 Implant's primary stability is another prerequisite to achieve osseointegration. Studies have shown that dental implants can integrate with surrounding bone if they have less than 100 microstrain or less than 150 micron micromovement [105–109]. Early loading of dental implants do not interfere with surrounding bone mineral apposition speed and osteogenesis phases continues to integrate with implant surface if primary stability is achieved [105–111]. Osteoblast phenotype morphology and physiology are not altered in immediately or early loaded implants [108, 110]. Adequate primary stability for a dental implant could be interpreted by insertion torque values greater than 30 N/cm2 . Primary stability and in the following time period stability of implants could be measured by use of Resonance Frequency Analysis (RFA) method [112–114]. RFA works by vibrations transmitted to implant body and measurement of implant's resistance values in numbers expressed in Implant Stability Quotient (ISQ ) units. Studies conducted with RFA showed that peri-implant bone strength follows Normal Distribution Curve (bell curve) as seen in many natural phenomena. Initial strength of interfacial bone to the implant due to inflammatory reactions and acidic environment decreases and reach the weakest point in the third week after implant placement. Meanwhile mineral apposition and developing ossification take place and secondary stability increase after third week to reach initial stability ISQ values approximately in the sixth week. The studies made on micro-movement and micro-strain have shown the possibility of osseointegration in immediate loading situation unless the threshold of 100 micron of mobility is not exceed [105–107]. Based on such results, it has been introduced 'immediate loading' protocol by use of splinted implants for totally edentulous patients [106, 109]. There are promising results and developing

protocols of immediate loading for partially edentulous and missing single-tooth cases, where the requirements are presence of primary stability more than 30 N/cm2 , implant length more than 10 mm, implant diameter more than 3.75 mm for titanium or zirconia dental implants and 3.3 mm for titanium-zirconia alloy implants, rigid splint of implants (in partially edentulous cases), non-functional loading, temporization (immediate delivery of provisional crowns or bridges to shape soft tissue contours). In patients where there are short implants but adequate primary stability, or patients with parafunctions, patients with low density bone (type III or IV), 'early loading' protocol which previews 6 weeks healing period can be applied. If the primary stability of an implant is less than 30 N/cm2 insertion torque, healing period should be elongated to 3 months for the lower and 6 months for the upper jaw bones which is called 'delayed loading' protocol as proposed by Branemark at the beginning years of modern scientific implant dentistry.

TDI cases mostly involve anterior maxilla with early or delayed loss of single tooth (except gunshots) which is mainly central incisor. In single-tooth replacements there are special rules to follow in order to obtain suitable esthetics. Maintenance of soft tissue envelope contours and the presence of papillae are highly important. The preservation of soft tissue integrity is related to flap nutrition, thus flapless surgery is the primary choice. The 'tunnel technique' may be an alternative to conventional open flap surgery and graft application, in order to apply minimally invasive surgery. Another approach is to avoid vertical release incisions and apply only sulcular incision to keep intact vessels of flap and cause less reduction of blood supply.

 Papilla protective flap design is thought to preserve papillae, where two vertical incisions exclude papillae in both distal and mesial sides and a narrow full thickness flap band is raised. In long term follow-ups it has been noted that those two vertical incisions lead the formation of scar areas which would apparent on the buccal side of mucosa. On the other hand, in case of intra-operative treatment plan change, upon need of augmentation, the graft materials would be under incision lines. The presence of incisions on the grafted area will increase microbial contamination risk of graft by micro-leakage and cause inadequate blood supply to the graft. Thus, papilla protective flap design is almost a disappeared technique.

The second rule to follow in single-tooth replacements is the preservation of buccal bony wall. In jaw bones anatomy, buccal portion of alveolar bones is mostly very thin [115–117]. This thin buccal wall would be resorbed rapidly due to acidic inflammatory environment which may take place in case of nutrition lack due to flap raising, or after trauma and post-traumatic extraction where crestal bone could be fractured. To avoid traumatic extractions periotomes, electro-dynamomagnetic device inserts, piezoelectric device inserts, special extraction drill-chain appliances, very thin Er:YAG laser sapphire tips are developed. 'Ridge preservation' techniques which aims to immediately graft extraction sockets to avoid future resorptions are proposed. Some authors proposed not only hard tissue grafting but also mucosa transplants by punch technique to cover entirely socket orifice. On the horizontal plane palato-position of the implant placement is another rule to follow to preserve buccal width of alveolar bone. Palato-position of an implant is obtained by centering the insertion point of first drills on the palatal wall of the socket, but not to the apical bottom; the location should be slightly palatal to the inter-incisal line of adjacent teeth. Plato-positioning helps also to balance the future unavoidable senile resoption pattern of buccal alveolar bones which is physiological. A single-tooth implant should keep equal distance to the neighboring teeth. The collar platform level of the single-tooth implant should not be embedded more than 2 mm apically from the cementoenamel junction (CEJ) of adjacent teeth. If the implant collar exceeds CEJ criteria, longest crowns in comparison to natural dentition should be

#### *Dental Implants and Trauma DOI: http://dx.doi.org/10.5772/intechopen.81202*

 fabricated and the future bacterial colonization of inner implant spaces will execute pumping effect of contaminants deriving from the micro-gaps between abutmentimplant connection during chewing cycles which will result in collar area bone resorption and subsequent mucosal recessions and papilla loosening.

In adolescent patients who completed their skeletal growth and in adults after traumatic loss of teeth if the available soft tissue and bone volumes are favorable, implants could be placed immediately. Immediate implant placement may be excluded when the soft tissues have lost their integrity to cover wound area by tension-free flaps; or when hard tissues have great volume loss and primary anchorage possibility would poor (e.g., traffic accidents, gunshots). In such situations primary wound healing should be waited. The risk in immediate implant placement after trauma is associated with the contamination of defect area by foreign bodies and microorganisms. To clean extraction socket generally conventional curettage is followed. But bacterial contamination can still persist within the lamina cribrosa of socket or in the spongy bone. The best method to avoid contaminants and bacteria from the wound area would be usage of Er:YAG laser irradiation associated with conventional curettage as the studies have shown Er:YAG's high bactericidal effect against microbiota [118–120].

 In the anterior region of jaws titanium implant body and abutment reflection may be apparent by time as buccal bone senile resorption pattern is from distal (outside) to medial (inside). Solution to mask metallic reflection is the usage of ceramic materials. Recently full ceramic zirconia implants and abutments gained again popularity. After first attempts of alumina implants in the 1970s and their mechanic failures caused an interval of approximately 30 years. In last two decades, firstly CAD/CAM zirconia abutments and following one-piece zirconia and recently two-pieces zirconia implants were introduced in the market. Nowadays most sophisticated applications of single-tooth replacements are made by full ceramic implants, zirconia-titanium or titanium implants and zirconia abutments supporting leucite-reinforced ceramic or lithium disilicate ceramic crowns.

Future trends and strategies in dental traumatology in general and with special attention to dental implant applications are based on the education of population in terms of emergency treatments and urgent transport of patients to the clinics; trained clinics on emergency treatments; preparation of patients to future implant rehabilitations by interim treatment which care preservation of hard and soft tissues.

#### **5. Conclusions**

Edentulism due to trauma could be properly rehabilitated by dental implant placements. Reports in the literature have been adequately evidenced safe usage of dental implants after traumatic injuries. There are various considerations to plan suitable treatment option in the edentulous areas of jawbones after trauma. At the first side the systemic conditions of patient should permit dental implant surgery. Secondly the skeletal age of patient should be adequate to implant placement as it is shown that implants do not migrate following bony development and embed in an infra-occlusion by time. The third level of consideration is the availability of soft and hard tissues. Rehabilitation strategies are developed according to the defect size, volume, tridimensional shape of hard tissues and biotype of soft tissues. Special attention is paid to preserve mucosal contours and papillae by use of flapless technique or proper incisions, as well as hard tissue augmentation options are planned taking in consideration the available vascularity, defect wall number, bone height and fixation of graft material. In the implant placement phase the primary

#### *Trauma in Dentistry*

stability is the main target in order to initiate osseointegration. There are several implant insertion techniques such as drilling, narrow drill/wider implant, osteotome, bone splint and laser-assisted which are decided basing on possible primary anchorage within the residual bone. After achievement of primary stability it should be decided the loading type of implants which is related to implant number, localization, length, diameter, splinting options. Basically functional immediate, non-functional immediate, early or delayed loading protocols can be applied. Once loading protocol is fixed it should be emphasized the prosthetic supra-structure design and material. In conclusion missing teeth due to trauma could be successfully rehabilitated by dental implants following detailed and careful diagnosis in order to establish proper individual treatment plan and by application of consecutive treatment steps.

#### **Author details**

Tosun Tosun1 \* and Koray Meltem2

1 Department of Oral and Maxillofacial Surgery, Dental School, Istanbul Aydin University, Istanbul, Turkey

2 Department of Oral and Maxillofacial Surgery, Dental School, Istanbul University, Istanbul, Turkey

\*Address all correspondence to: tosuntosun@aydin.edu.tr

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Section 3 Material

**41**

**Chapter 3**

**Abstract**

and dental students.

**1. Introduction**

new bone tissue [3, 4].

Patients

Biomaterial Used in Trauma

*Mehmet Yaltirik, Meltem Koray, Hümeyra Kocaelli,* 

The development of bone tissue engineering and bone regeneration is always of interest to improve methods to reduce costs of trauma patient. Ability to use autogenous bone forming cells attached to bone morphogenetic proteins would be ideal. There are many clinical reasons to develop bone tissue engineering alternatives, for use in the reconstruction of large defects and implants. The traditional methods of bone defect management include autografting and allografting cancellous bone, vascularized grafts, and other bone transport techniques. However, these are the standard treatments. Since bone grafts are avascular and dependent on the size of the defect, the viability can limit their application. In large defects, the grafts can be resorbed by the body before osteogenesis is complete; tissue loss develops in the living organism due to infection, trauma, congenital, and physiological reasons. Placing tissue defects in the dentist and maxillofacial surgery and accelerating wound healing are an important issue. From an old Egypt, material used in treatment of different doctors with various causes. Oral surgery, periodontology, and implantology, which are surgical branches of the dentistry, need to increase bone formation in the treatment of bone defects, congenital defects, and defects around the implant. Many years of work have been done to obtain ideal biomaterials, and many materials have been used. We have prepared detailed information on biomaterials used in dentistry, oral, and maxillofacial surgeries in this book to help dentists

*Duygu Ofluoglu and Cevat Tugrul Turgut*

**Keywords:** biomaterials, trauma, maxillofacial surgery

Bone not only supports and protects various organs but it also facilitates mobility [1], with the help of the soft collagen protein and stiffer apatite mineral. Bone is maintained dynamically through two different processes: modeling and remodeling [2]. In bone modeling process, the new bone is formed without prior bone resorption, while in the bone remodeling process, bone formation follows bone resorption [1]. Bone remodeling is a lifelong process that begins in early fetal life and is maintaining bone function by continuously replacing damaged bone with

The use of alloplastic materials in the remodelization of traumatized lesions and fractures in the compensation of tissues lost for various reasons such as trauma first started in ancient Egypt [5]. All substances are called biomaterials, which help to

#### **Chapter 3**

## Biomaterial Used in Trauma Patients

*Mehmet Yaltirik, Meltem Koray, Hümeyra Kocaelli, Duygu Ofluoglu and Cevat Tugrul Turgut* 

#### **Abstract**

 The development of bone tissue engineering and bone regeneration is always of interest to improve methods to reduce costs of trauma patient. Ability to use autogenous bone forming cells attached to bone morphogenetic proteins would be ideal. There are many clinical reasons to develop bone tissue engineering alternatives, for use in the reconstruction of large defects and implants. The traditional methods of bone defect management include autografting and allografting cancellous bone, vascularized grafts, and other bone transport techniques. However, these are the standard treatments. Since bone grafts are avascular and dependent on the size of the defect, the viability can limit their application. In large defects, the grafts can be resorbed by the body before osteogenesis is complete; tissue loss develops in the living organism due to infection, trauma, congenital, and physiological reasons. Placing tissue defects in the dentist and maxillofacial surgery and accelerating wound healing are an important issue. From an old Egypt, material used in treatment of different doctors with various causes. Oral surgery, periodontology, and implantology, which are surgical branches of the dentistry, need to increase bone formation in the treatment of bone defects, congenital defects, and defects around the implant. Many years of work have been done to obtain ideal biomaterials, and many materials have been used. We have prepared detailed information on biomaterials used in dentistry, oral, and maxillofacial surgeries in this book to help dentists and dental students.

**Keywords:** biomaterials, trauma, maxillofacial surgery

#### **1. Introduction**

 Bone not only supports and protects various organs but it also facilitates mobility [1], with the help of the soft collagen protein and stiffer apatite mineral. Bone is maintained dynamically through two different processes: modeling and remodeling [2]. In bone modeling process, the new bone is formed without prior bone resorption, while in the bone remodeling process, bone formation follows bone resorption [1]. Bone remodeling is a lifelong process that begins in early fetal life and is maintaining bone function by continuously replacing damaged bone with new bone tissue [3, 4].

The use of alloplastic materials in the remodelization of traumatized lesions and fractures in the compensation of tissues lost for various reasons such as trauma first started in ancient Egypt [5]. All substances are called biomaterials, which help to

eliminate any deficiencies in the living organism and help the organism to complete this deficiency regularly and quickly [5].

 Bone grafting is one of the most common surgical procedures to set up bone regeneration procedures [6]. Bone grafting procedures were the second most frequent tissue transplantation after blood transfusion [7]. Autologous bone is still gold standard in bone regeneration [8]. Bone grafting procedures vary between natural grafts to synthetic bone substitutes and biological factors [9]. Synthetic bone substitutes and biological factors, calcium phosphate (CaP) based biomaterials (e.g., hydroxyapatite (HAp), CaP cements, and ceramics), and recombinant human bone morphological proteins (rhBMPs) are most frequently used [10].

This chapter will describe the biomaterials used in the reconstruction of defects in the head and neck region [5].

#### **2. Structure of bone**

Bone is a connective tissue that forms the skeleton of the body, acts as a support to the muscles and organs, protects them against. Bone tissue consists of two different bone structures as compact or cortical spongiosa or cancellous bone [5].

Bone tissue is examined in two separate parts: the matrix between the cells and the cells [5].

#### **2.1 Cells**

#### *2.1.1 Osteoprogenitor cells*

These cells are the result of differentiation of stromal cells arising from embryonal mesenchymal cells in periosteum and endosteum. Cells related to direct bone formation are osteoblasts, osteocytes, connective tissue, fibroblast, and fat cells.

#### *2.1.2 Osteoblasts*

 They play a role in the synthesis, preparation, and mineralization of the bone matrix. They are then implanted into the tissue with calcification of the bone matrix to become osteocytes.

#### *2.1.3 Osteocytes*

 They surround with osteoblasts, mineral matrix and then consequent balance of the calcium (Ca) level.

#### *2.1.4 Bone marrow cells*

They are cells similar to squamous epithelial cells found in inactive regions in the bone.

#### *2.1.5 Osteoclasts*

Osteoclasts digest the mineral matrix of the bone with acid phosphatase, which they secrete, and then resorb it by digesting collagen and other organic matrix structures with lysosomal enzymes.

#### **2.2 The intercellular tissue (bone matrix)**

Cell-to-cell tissue forms 10–29% water, 60–70% of the bone dry weight is the inorganic structure (bone salts), and 30–40% of the bone dry weight, 90–96% of the organic structure is collagen, which is also the main component of connective tissue and constitutes one-third of all body proteins [5].

#### **3. Healing mechanism of bone defects**

Bone repair can be defined in two procedures: primary bone healing and secondary bone healing. The large segmental bone loss in the defect is an extreme condition in bone healing, which can be caused by trauma, diseases, developmental deformities, revision surgery, and tumor resection or osteomyelitis [11, 12].

Primary (direct) bone healing mainly happens when the fracture gap is less than 0.1 mm, and the fracture site is rigidly stabilized. Secondary bone healing is the more common form of bone healing and occurs when the fracture edges are less than twice the diameter of the injured bone [11]. Blood clothing, inflammatory response, fibrocartilage callus formation, membranous ossifications, and bone modeling are involved in bone healing.

Bone substitutes mainly involve three important biological properties: osteogenesis osteoinduction, and osteoconduction [13].

#### **3.1 Bone formation mechanism with bone graft materials**

#### *3.1.1 Osteogenesis*

 Bone graft materials in osteogenesis include organic materials that have bone formation capacity directly from osteoblast cells. Even in environments where undifferentiated mesenchymal cells are not present in the tissue, such organic materials have the ability to be osteogenic. The only graft material with osteogenic character is autogenous bone. Autogenous bone is obtained from the oral surgery, iliac bone, tuber maxilla, and mandibular symphysis [5].

#### *3.1.2 Osteoinduction*

Osteoinduction, with osteoinductive materials, has the capacity to convert undifferentiated mesenchymal cells in tissue into osteoblasts and chondroblasts. In oral surgery, bone allografts are the most commonly used osteoinductive materials. Bone allograft is derived from different human bone tissues with different genetic structure.

#### *3.1.3 Osteoconduction*

The growth of bone tissue with osteoconduction is characterized by the formation of appositional bone. That is why osteoconduction occurs in the presence of bone or undifferentiated mesenchymal cells.

 As a result, although bone has a very variable metabolism, resistance depends on the amount of collagen, the arrangement of fibrils, the presence of minerals, and the presence of minerals on proteins and glucosamines.

### **4. Basic features of biomaterials**


#### **5. Classification of biomaterials**

	- a.Autogenous bone graft (autograft)
		- I. Cortical and cancellous bone in or out of mouth
	- b.Homogeneous bone graft (allograft)
		- I. Isograft: fresh cancellous bone marrow
	- II. Fresh frozen bone
	- III. Frozen dried bone

*Biomaterial Used in Trauma Patients DOI: http://dx.doi.org/10.5772/intechopen.81004* 

	- I. Demineralized bone
	- a.Tissue sources
		- I. Dentin
		- II.Cementum
	- III. Cartilage

IV.Sclera


#### **5.1 Bone source biomaterials**

In the treatment of traumatic defects, congenital deformities, tumor surgery are in used. Today, homogeneous bone grafts (allografts), heterogeneous bone grafts (xenografts), and alloplastic materials are used in oral and maxillofacial surgery [5].

 An osseous graft from an anatomic site and transplanted to another site within the same individuals is called autologous bone grafting [14, 15]. With osteoconductive, osteoinductive, and osteogenic properties, an autologous bone graft can integrate into the host bone more rapidly and completely [15]; therefore, it is regarded as the gold standard bone defects [16].

Cancellous autografts are the most commonly used form. Few osteoblasts and osteocytes, but abundant mesenchymal stem cells (MSCs), survive as a result of ischemia during transplantation, which helps maintaining osteogenic potential and the ability to generate new bone from the graft [17]. Autograft-derived proteins, which are attributed to the osteoinduction of the graft, are also preserved and present when the autografts are appropriately treated [15, 18].

Cortical autografts have excellent structure and are mechanically supportive, due to osteoprogenitor cells [14]. Unlike the autologous cancellous graft, the creeping substitution of cortical autograft is mainly mediated by osteoclasts after the rapid hematoma formation and inflammatory response in early phase of bone regeneration, since the revascularization and remodeling processes are strictly hampered by the dense architecture [15].

#### *5.1.1 Autogenous bone graft (autograft)*

Autogenous grafts: the fresh autogenous graft taken from the same organism contains osteogenic cells and does not cause an immunological reaction; this group is the most advantageous graft material. However, the disadvantages of this group include the need for a second operation in the donor area, long-term postoperative pain and limitation of movement, and prolonged maintenance. Autogenous bone grafts can be obtained from crista iliaca: grafts costal grafts and cranial bones, structurally separated as cortical bone, cancellous, and corticocancellous bone [5].

*Intraoral cancellous bone*: Upper jaw tuber region, toothless regions, exocytoses, recovery sites ramus mandibula, interlobar alveolar bone, lower jaw semispherical region and ramus mandibula, and bone fragments arising during operation [5].

*Oral cancellous bone*: The iliac bone is obtained from bone, ribs, and other endochondral bones.

*Corticocancellous bone*: The corticocancellous bone does not have the osteogenesis-enhancing properties as cancellous bone. This type of graft is most commonly of rib or ilium origin [5].

#### *5.1.2 Homogeneous bone graft (homograft)*

An autogenous bone graft is obtained from the individual itself.

*Isograft*: The tissues taken from living things with the same genetic structure as the recipient are called isografts or syngenesioplastic grafts.

Allografts are tissues from the same species but from living things that are genetically identical to the recipient. Bone allografts are obtained from human beings of different genetic types and from bones extracted from humans, such as cadavers or hip fractures, and are maintained in bone banks by a series of procedures [11]. It has many advantages compared to being obtained from living people. The advantages are elimination of donor site, reduction of anesthesia and duration of operation, loss of blood loss and complications at low level. The disadvantage is that the touch is taken by another person [5].

 Considering the limitation of autologous bone grafts is the best alternative to autografts and has been used effectively in clinical practice in many cases, especially for patients who have poor healing potential, established nonunion, and extensive comminution after fractures [15, 17]. The allograft may be machined and customized and is therefore available in a variety of forms, including cortical, cancellous, and highly processed bone derivatives [14]. Allografts are found to be immunogenic and have higher failure rate, which are believed to be caused by activation of major histocompatibility complex [19].

Cancellous allografts are the most common types of commercial allogeneic grafts and are supplied predominately in the form of blocks [14]. Compared to autografts, a similar but slower sequence of events happens in the incorporation process of allografts [15].

Cortical allografts confer rigid mechanical properties and are mainly applied in spinal augmentation for filling large defects [14]. In consideration of immune

#### *Biomaterial Used in Trauma Patients DOI: http://dx.doi.org/10.5772/intechopen.81004*

responses and for safety, frozen or freeze dried products that are free of marrow and blood are commonly transplanted [15].

Demineralized bone matrix is highly processed allograft derivative with at least 40% of the mineral content of the bone matrix removed by the acid, while collagens, noncollagenous proteins, and growth factors remain [17].

Demineralized bone matrix osteoconductivity is conferred by providing a framework for cell populating and for generating new bone after the treatment [18]. Osteoinductive property of demineralized bone matrix is mainly determined by the remaining growth factors, which are directly correlated with preparation methods. Demineralized bone matrix is similar to that of the autogenous graft, with growth factors triggering an endochondral ossification cascade and culminating in new bone formation at the site of implantation [18].

Recent techniques in preparing immunoglobulin complications of allografts to remove the disease carrying potentials are freezing, freezing and drying, or exposure to radiation. The applied bone has a slower revascularization and more resorptive activity than autogenous grafts [5].

The mechanism of revascularization begins with an acute infinite response and lasts for a long time, followed by chronic infilamations. It meets cellular immunological response in frozen bone applications.

#### *5.1.3 Heterogeneous bone graft (xenograft)*

Heterogeneous bone grafts are called grafts from a different species. The heterogeneous term is used for tissues from different species. Heterogeneous bone grafts have been proposed to fill small jaw defects, and many clinicians have indicated that these grafts have any osteogenic potential but instead are matrix for bone formation. Studies done with inorganic calf bone showed successful results in graft osteotomy sites but not in posttraumatic deformity and hypoplastic area corrections [5].

#### *5.1.3.1 Clinical use of the allogeneic bone*

Allogeneic bones prepared for different frozen, dried, or frozen oral surgical procedures are available in different anatomical shapes. Cancerous iliac bone is divided into particles of about 2–10 mm in diameter for use in bone defects. Small cancellous particles are used in the periapical areas after curettage with limited alveolar edge corrections [5].

 Researchers who have expected to make use of osteoconductive effects of alloplastic bone materials (hydroxylapatite, tricalcium phosphate, etc.) and bone allografts and autogenous bone grafts cause postoperative complications in the donor area have been directed to obtain bone grafts with both osseoinductive and osseoconductive allogenic, low antigenic properties. For this purpose, autolyzed, degenerated (allogenic) bone was studied. In contrast to lyophilized or other allogenic human bones, researchers indicate that the allogenic bone is osteoconductive. The use of lyophilized and sterile human allogenic bone in parts or powder forms is offered. The powder forms of this bone are suggested for filling the cyst cavity [5].

#### **5.2 Bone-free biomaterials (alloplasts)**

 Allogenic grafts which lost vitality have been seen, organic, and inorganic inanimate materials and synthetic materials obtained from animals such as ceramic hydroxylapatites, tricalcium phosphates, and various "alloplastic materials."

The most important problem in the alloplastic material is the tendency of the immunological system to encapsulate and isolate foreign bodies [5].

#### *Trauma in Dentistry*

 Alloplasts have been using in bone defects due to various reasons, such as cranial, mandibular, maxillary, nasal, zygomatic, TME reconstructions, or traumatic augmentations, are metals, polymers, hydroxylapatite, and associated calcium triphosphate ceramics or combinations of these materials.

#### *5.2.1 Tissue sources*


IV.Sclera

V.Dura mater

#### *5.2.2 Metals*

Metal biomaterials are widely used in electrosurgical surgery, orthognathic surgery, and orthopedic surgery. Metallic stiffness is a desirable feature for implants that will encounter load force, especially during functioning. The metal groups used are alloys such as gold, platinum, stainless steel, titanium, and chromium-cobalt.

Bioinorganic ions, such as silicon, magnesium, strontium, zinc, and copper, can still be regarded as essential cofactors of enzymes, coenzymes, or prosthetic groups [20].

 Mechanism of magnesium ions on fracture healing is not yet fully explained; recent investigations showed that the osteogenerative effect of Mg2+ on undifferentiated human bone marrow stromal cells (hBMSCs) and osteogenic hBMSCs was likely attributed to connected the subsequent orchestrated [20].

Strontium to reduce bone resorption and osteoclast activity [20] were also observed under rat osteoclasts and primary mature rabbit osteoclasts, respectively. The adverse effect of strontium in cardiovascular diseases and venous thrombosis has been highlighted [20].

Silicon is a silica-based synthetic bone substitute, which is used in orthopedic; bioglass cannot be ignored when discussing the effect of silicon on bone regeneration. Bioglass has a key role because of the fact that the hydroxyapatite coating, but not the leaching silicon ions, played an active role in the processes leading to new bone formation [19]. Zinc is involved in the structural, catalytic, or regulatory action of several important metalloenzymes, and alkaline phosphatase (ALP) is among them. ALP not only generates phosphates by hydrolyzing pyrophosphates but also creates an alkaline environment, which favored the precipitation and subsequent mineralization of these phosphates in the extracellular matrix, which were produced by osteoblasts [20].

Copper has been recognized as a cofactor for several other enzymes in body, one of which is related to the musculoskeletal system [20]. Lithium has attracted attention due to its role in osteogenesis [20]. Like copper, cobalt was recently showed to stimulate angiogenesis [20].

#### *Biomaterial Used in Trauma Patients DOI: http://dx.doi.org/10.5772/intechopen.81004*

#### *5.2.3 Gelatin film*

It can be used as resurfacing, porous, nonantigenic, and in the middle ear surgery for pleural injuries in dura mater application.

#### *5.2.4 Polymers*

Polymethylmethacrylates are self-polymerized acrylics that are identified as bone cement.

Polymethylmethacrylate (PMMA) remains a key component of modern practice and is nonbiodegradable and nonresorbable, which makes it more like grouting than cement, and thus cannot be considered a bone substitute material, which is used in clinics [19].

#### *5.2.5 Calcium sulfate*

When combined with other synthetic bone substitutes and/or growth factors [20], one of the promising approaches is to load antibiotics to this biomaterial.

#### *5.2.6 Calcium carbonate*

The outer layer of corals in the calcium carbonate structure releases a calcareous substance called aragonite. The physical structure is similar to cancellous bone and consists of trace elements such as 98% calcium carbonate, 2% fluorine, zinc, copper, iron, and strontium. It is an excellent tissue-compatible material that can completely resurface during the healing process and has an osteoconductive effect on new bone formation [5].

#### *5.2.7 Calcium phosphate*

Calcium phosphate material is similar to HA in terms of its behavior in the tissue. However, calcium phosphate has the most pronounced multiplication property, which is closely related to bone without the need for porosity.

#### *5.2.8 Calcium phosphate ceramics (CaP ceramics)*

 Calcium phosphate ceramics are calcium hydroxyapatites, which is a chemical composition similar to the mineral phase of calcified tissues [17]. Hydroxyapatite (HAp) is occurring mineral form of calcium apatite with the formula of Ca10[PO4]6[OH]2 and comprises about 50% of the weight of the bone, which accounts for its excellent osteoconductive and osteointegrative properties [14, 17].

#### *5.2.9 Bioactive glass*

Bioactive glass, known as bioglass, refers to a synthetic silicate-based ceramics and was originally constituted by silicon dioxide (SiO2), sodium oxide (Na2O), calcium oxide (CaO), and phosphorus pentoxide (P2O5) [20]. The optimized constitutions lead to a strong physical bonding between bioglass and host bone. If hydroxyapatite coating on the surface of bioglass takes place, it absorbs proteins and attracts osteoprogenitor cells [20].

#### **6. Principles of biomaterial trauma applications**

Correcting the deformities, the first thing to note in augmentation is the presence of the epithelium that can cover the implanted material completely and without tension. In cases where deformity is common and tissue loss is large, skin and soft tissue transplantation may be required before biomaterial is applied. If the defect in the bone tissue is too large, graft should be considered, and functional stress in the receiving area, load, and the trauma to it should be considered.

Bone defect may result in delayed union or even nonunion if the treatment is improper. Therefore, bone grafting techniques should take place in the surgical process. Even though various synthetic bone substitutes offer diversity options, the treatment outcome is still incomparable to the autologous bone graft in terms of bone healing quality and time management. Ions such as magnesium, strontium, silicon, copper, and cobalt are feasible solution for bone defect. Therapeutic effect and mechanism of ions have been understood. Bioinorganic ions can be applied with growth factors and induce new bone formation.

 Every surgeon should use the technique in the direction of the prepared plan, determine the biomaterial, and apply it on the model. Atraumatic work should be performed as much as possible during the operation, the material used should conform to the defect contours, the stabilization should be esthetic of the patient, and the appropriate tools should be used in the biomaterials during surgery to manipulate the material so as not to create sharp or irregular edges. Stabilization is provided by sewing, wire, and nails. Good closure of the incision is important in the postoperative period. Careful evaluation of each phase will ultimately bring success.

#### **Acknowledgements**

This chapter was performed by Mehmet Yaltirik, Meltem Koray, Hümeyra Kocaelli, Duygu Ofluoglu, and Cevat Tugrul Turgut in Istanbul University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery.

#### **Conflict of interest**

We declare that there is no conflict of interest with any financial organization regarding the material discussed in the chapter.

*Biomaterial Used in Trauma Patients DOI: http://dx.doi.org/10.5772/intechopen.81004* 

### **Author details**

 Mehmet Yaltirik\*, Meltem Koray, Hümeyra Kocaelli, Duygu Ofluoglu and Cevat Tugrul Turgut Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, Turkey

\*Address all correspondence to: mehmet.yaltirik@istanbul.edu.tr

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Fonseca RJ, Walker RV. Oral and Maxillofacial Trauma. Vol. II. Philadelphia, WB: Saunders Company; 1991

[2] Guyton AC. Tibbi Fizyoloji. In: Textbook of Medical Physiology. 7th ed. Philadelphia: WB Saunder Company; 1986. pp. 937-953

[3] Kikırdak GY. Kemik ve Biyokimyasl. İ.Ü.Diş.Hek.Fak. Biyokimya Bilim Dali Ders NotIan. 1988:**37**;300-391

[4] Jaffe HL. Metabolic, Degenerative and Inflammatory Diseases of Bones and Joints. Munchen, Berlin, Wien: Urban and Schwarzenberg; 1972. pp. 44-104

[5] Tuskan C, Yaltirik M. Oral ve Mksillofasiyal Cerrahide Kullanılan Biyomateryaller. İstanbul: Istanbul Universitesi Yayinlari İstanbul; 2002. pp. 1-54

[6] Amler MH, LeGeros RZ. Hard tissue replacement polymer as an implant material. Journal of Biomedical Materials Research. 1992;**24**:1079-1089

[7] Archer WH. Oral and Maxillofacial Surgery. 5th ed. Vol. II, 1975. Philadelphia: WB Saunders Company. pp. 1512-1526

[8] Aukhil I, Simpson DM, Sugss C, Petterson E. In vivo differentiation of progeniton cells of the periodontal ligament. An experimental study using physical barriers. Journal of Clinical Periodontology. 1986;**13**:862-868

[9] Bovde A, Wolfe LA, Jones SJ, Vesely P, Maly M. Microscopy of bone cells, bone tissue and bone healing around implants. Implant Dentistry. 1992;**1**:117-125

 [10] Braley S. The silicones in maxillofacial surgery. Laryngoscope. 1968;**78**:549

[11] Kasaboğlu Ç. Normal ve diabetli stçanlarda kemik travmasmdan sonra kan serumunda görülen degişiklilerin incelenmesi [thesis]. Istanbul: Istanbul Universitesi; 1986

[12] Nayir E. DişhekimIiği Maddeler Bilgisi. 7th ed. İstanbul; 1999. pp. 25-39

[13] Schaffer AB. The combined use of hydroxyapatite segments and granules for alveolar ridge reconstruction. Oral and Maxillofacial Surgery. 1993;**51**:26

[14] Smith EL, Hill RL, Lehman R, Lefkowitz R J, Handler F, White A, Principles of Bio-chemistry. International student ed. 1983. pp. 15-18

[15] Soydan N. Genel Histoloji, Taş Matbaası. Istanbul: Istanbul Universitesi; 1985. pp. 100-119

 [16] Wismeijer D, Vermeeren JIJH, Van Waas MAJ. Patient satisfaction with overdentures supported by one-stage TPS implants. The International Journal of Oral & Maxillofacial Implants. 1992;**7**:51-55

 [17] Albrektsonn T, Zarb G, Worthington P, Ericsson A. The long term efficacy of currently used dental implants. Journal of Oral and Maxillofacial Implants. 1986;**1**:11-25

[18] Sandalll F, Karabuda C. Oral implantolojide kemik grefti materyalleri ve kullamlan. Oral Implantoloji Dergisi. 1999;**1**:9-16

[19] Bouchard P, Ouhayoun JP, Nilveus RE. Expanded polytetrafluoroethylene membranes and connective tissue grafts support bone regeneration for closing mandibular Class II furcations. Journal of Clinical Periodontology. 1993;**54**:1193-1198

[20] Wang W, Yeung KWK. Bone grafts and biomaterials substitutes for bone defect repair: A review. Bioactive Materials. 2017;**2**:224-247

Section 4 Pediatrics

**55**

**Chapter 4**

**Abstract**

will be discussed.

matic dental injuries.

oral injuries [1–8].

Dentistry

*and Pinar Kiymet Karataban*

Dental Traumatology in Pediatric

In this chapter, epidemiology of dental trauma will be discussed in terms of its incidence and prevalence among primary and permanent dentition. Dental trauma causes and its distribution in accordance with age and sex will be highlighted. Classification of dental trauma based on soft and hard tissue injuries will be outlined, and subsequently, clinical examination and diagnosis will be featured. Treatment modalities and variations between permanent and primary dentition will be discussed along with the new treatment era namely regenerative approach and decoronation. Splints, techniques, and follow-up routines will also be discussed. Last but not least, prevention of dental trauma

Traumatic dental injuries are a public dental health problem worldwide and can occur throughout life. Various interventions and treatment options are available, depending on the specific traumatic injury sustained, but the fact is, every trauma is

The International Association of Dental Traumatology reports that one of every two children sustains a dental injury, most often between the ages of 8 and 12 years. The suggestion is in most cases of dental trauma; a rapid and appropriate intervention can lessen its impact from both oral and esthetic standpoint. To that end, the association has developed guidelines for the evaluation and management of trau-

Although the oral region comprises a small part as 1% of the total body area, 5% of all bodily injuries are oral traumatic injuries. Traumatic dental injuries tend to occur at childhood or an young age during which growth and development take place. In preschool children, with injuries to the head being the most common, oral injuries make up as much as 17% of all bodily injuries, in contrast to later in life

Dental injuries are the most common and are seen in as many as 92% of all patients seeking consultation or treatment for injuries to the oral region. Also, softtissue injuries are seen in 28%, simultaneously with dental injuries, and fractures involving the jaw are seen more rarely, in only 6% of all patients presenting with

*Asli Topaloglu Ak, Didem Oner Ozdas, Sevgi Zorlu* 

**Keywords:** dental trauma, children, splints, classification

**1. An epidemiological approach to dental traumatology**

a unique case, which requires unique diagnosis and treatment.

when injuries to hands and feet are the most common.

#### **Chapter 4**

## Dental Traumatology in Pediatric Dentistry

*Asli Topaloglu Ak, Didem Oner Ozdas, Sevgi Zorlu and Pinar Kiymet Karataban* 

#### **Abstract**

 In this chapter, epidemiology of dental trauma will be discussed in terms of its incidence and prevalence among primary and permanent dentition. Dental trauma causes and its distribution in accordance with age and sex will be highlighted. Classification of dental trauma based on soft and hard tissue injuries will be outlined, and subsequently, clinical examination and diagnosis will be featured. Treatment modalities and variations between permanent and primary dentition will be discussed along with the new treatment era namely regenerative approach and decoronation. Splints, techniques, and follow-up routines will also be discussed. Last but not least, prevention of dental trauma will be discussed.

**Keywords:** dental trauma, children, splints, classification

#### **1. An epidemiological approach to dental traumatology**

Traumatic dental injuries are a public dental health problem worldwide and can occur throughout life. Various interventions and treatment options are available, depending on the specific traumatic injury sustained, but the fact is, every trauma is a unique case, which requires unique diagnosis and treatment.

The International Association of Dental Traumatology reports that one of every two children sustains a dental injury, most often between the ages of 8 and 12 years. The suggestion is in most cases of dental trauma; a rapid and appropriate intervention can lessen its impact from both oral and esthetic standpoint. To that end, the association has developed guidelines for the evaluation and management of traumatic dental injuries.

Although the oral region comprises a small part as 1% of the total body area, 5% of all bodily injuries are oral traumatic injuries. Traumatic dental injuries tend to occur at childhood or an young age during which growth and development take place. In preschool children, with injuries to the head being the most common, oral injuries make up as much as 17% of all bodily injuries, in contrast to later in life when injuries to hands and feet are the most common.

Dental injuries are the most common and are seen in as many as 92% of all patients seeking consultation or treatment for injuries to the oral region. Also, softtissue injuries are seen in 28%, simultaneously with dental injuries, and fractures involving the jaw are seen more rarely, in only 6% of all patients presenting with oral injuries [1–8].

Trauma has a multitude of consequences for the traumatized individual, family members, and society. The impact is not only physical but also psychosocial and economic. Every pediatric patient should be given the opportunity to receive a complete dental treatment for traumatic dental injuries, but a complete treatment plan involving participation of specialists in several disciplines can often be complicated and expensive. In contrast to many other traumatic injuries treated on an outpatient basis, traumatic dental injuries are mostly irreversible, and thus, treatment will likely continue for the rest of the patient's life [9–14].

Constructing a complete treatment plan can be challenging because of the diversity of evidence-based interventions and reported outcomes in clinical studies. Besides, there is evidence that clinical researchers may prefer reporting outcomes that enhance results—this is known as outcome reporting bias. International Association for Dental Traumatology suggests that this diversity and reporting bias shall be eliminated by a standardized trauma management guideline in order to make the outcomes relevant to patients, clinicians, and policy makers as findings of research are to influence practice and future research [15].

It has been reported that, anterior teeth, especially the maxillary central and lateral incisors are predominantly affected by traumatic dental injuries for both primary and permanent dentitions. Traumatic dental injuries generally affect a single tooth except certain trauma events, such as traffic accidents, violence, and sports injuries, which result in multiple tooth damage.

Besides its numerous beneficial effects, active participation in sports activities may increase the risk for traumatic injuries to oral and dental tissues. These injuries are most prominent in boxing, basketball, hockey, and soccer.

 Traumatic dental injuries in the primary dentition appear to be rather stable at approximately 30% in most studies. It is been reported that one-third of all preschool children have suffered from traumatic injuries to the primary dentition in most of the countries. Although variations were observed within and between countries, one-fourth of all school children and almost one-third of adults have also suffered traumatic injuries to the permanent dentition [16–19].

#### **2. Incidence and prevalence of dental trauma**

 The prevalence of dental injuries varies within countries regarding the research reports. According to two surveys in US, the prevalence of traumatic dental injuries varies between 18.4 and 16% in 6–20 years old and 27.1 and 28.1% in 21–50 years old age groups. In UK, dental trauma prevalence varies between 23.7 and 44.2% in 11–14-year age groups and mostly observed in schools [20–23]. In other European countries, the prevalence varies between 13.5 and 20.3% in 6–24-year age groups. In Middle East and Asia, the prevalence varies between 16.2 and 32% in 8–16 years old age groups as the 10–11 years age groups revealed the highest score. There is an absolute need for an international standardized trauma registration either being able to detect trends over time or to make reasonable comparisons between and within countries [24–32].

In most studies, it is been reported that the incidence of traumatic dental injuries in children shows a range of 1–3% in the population. The peak incidence for traumatic dental injuries per 1000 individuals is found up to 12 years of age. The incidence is lower in older ages. Boys are more often affected than girls.

The variation of both prevalence and incidence presented in the literature reflects the local differences, environmental variations, behavioral, cultural, and socioeconomic diversities as well as the lack of standardization in methods and classifications [12, 16, 33].

#### **2.1 Etiologic risk factors**

Etiologic factors are very much related to the age, gender, environment, and activity of the patient.

Age is an important factor, as school children and adolescent are the main groups who are mostly prone to traumatic injuries. It is estimated that 71–92% of all traumatic dental injuries occur before the age of 19 years; other studies have reported a decrease after the age of 24–30 years.

 While in preschool children, the most common cause of traumatic dental injuries are accidental falls, in school age children, injuries are often caused by sports activities or hits by another person. Traffic accidents and assaults are the predominant etiologic factors in adolescents and young adults, and oral injuries occur most frequently during leisure time and during weekends associated with the western lifestyle today.

Gender is also a risk factor as males experience traumatic dental injuries at least twice more often than females. Yet, recent studies have shown a reduction in this gender difference in sports, which might be due to an increased interest in sports among girls Traebert et al. reported that girls can be exposed to the same risk factors of TDI as boys, which is a characteristic of modern Western society. Thus, environment and the activities of a person are undoubtedly more determining factors of TDIs than gender.

Another factor to be pointed is that in many countries, an increasing number of old people are possessing their own teeth, which, in near future, may lead to the increase in prevalence of dental traumatic injuries due to accidental falls in geriatric population [16, 33–35].

#### **3. Guideline on management of acute dental trauma**

#### **3.1 Examination**

*Before making a treatment in trauma cases, dentist must check the circumstances written in below*:


*Access for risk of concussion or hemorrhage*:


#### **3.2 History**


#### **3.3 Examination**

Clinical examination consists of visual inspection, palpation, thermal testing, and electric pulp testing. First and foremost, account for all teeth:


 examination and diagnosis. These views are going to help the comparison of preoperative and follow-up of traumatized teeth.

### **3.4 Radiographs: AAE-recommended guidelines**


#### *3.4.1 Panorex*


#### **3.5 Types of dental trauma on hard tissue and pulp**

Enamel infraction Enamel fracture Enamel-dentin fracture Enamel-dentin-pulp fracture Crown-root fracture w/o pulp involvement Crown-root fracture with pulp involvement.

#### **3.6 Types of dental trauma on periodontal tissue**

Concussion Subluxation (loosening) Intrusive luxation (central dislocation) Extrusive luxation (partial avulsion) Lateral luxation Retained root fracture.

#### **3.7 Types of dental trauma on supporting bone**

Exarticulation (complete avulsion) Comminution of the alveolar socket Alveolar socket wall fracture Alveolar process fracture Mandible or maxilla fracture.

#### **3.8 Types of dental trauma on gingival or oral mucosa**

Gingival or oral mucosal laceration Gingival or oral mucosal contusion Gingival or oral mucosal abrasion (**Figures 1**–**3**) [9, 11–13, 15, 36, 37].

#### *Trauma in Dentistry*

#### **Figure 1.**  *Types of dental trauma: gingival laceration.*

**Figure 2.**  *Types of dental trauma: intrusive luxation (central dislocation).* 

**Figure 3.**  *Types of dental trauma: crown-root fracture with pulp involvement.* 

### **4. Dental trauma in primary dentition**

Pain treatment and prevention of teeth germs must be our main goal in the treatment strategy of the traumatized primary teeth. Due to behavioral management problems or a severe trauma with a soft tissue bleeding, treatment may be overlooked or limited to extraction. However, in the overall treatment, primary teeth must be followed up clinically and radiographically in the long term.

In this section, treatment of primary dentition will be explained based on IADT treatment guidelines.

**Enamel fracture**: this type of fracture involves only enamel. There is no radiographic abnormality observed. Sharp edges are recommended to be smoothened. There is no need for follow-up.

**Enamel dentin fracture**: fracture involves enamel and dentin. Pulp is not exposed. There is no radiographic abnormality observed. The relation between the fracture and the pulp chamber can be revealed. In case behavioral management is succeeded with the patient, involved dentin can be sealed completely with glass ionomer to prevent microleakage. Composite resin restorations are good choices if lost tooth structure is large. Clinical examination is required after 3–4 weeks.

**Crown fracture with exposed pulp**: fracture involves enamel and dentin and the pulp is exposed. Radiographic findings can reveal the stage of root development. Preservation of pulp vitality can be accomplished by partial pulpotomy. Unless there is an cooperation with the patient, extraction is an alternative treatment approach. Clinical follow-up is required after 1 week, 6–8 weeks, and 1 year. Radiographic follow-up is required after 6–8 weeks and 1 year as well (**Figure 4**).

**Crown/root fracture (without pulp exposure)**: this type of fracture involves enamel, dentin, and root structure. The pulp may or may not be exposed. Tooth displacement may be observed as well. Radiographical evaluation will reveal single/ multiple fragments of the traumatized tooth. In case the fracture involves only a small part of the root, only fractured fragment is removed and coronal restoration can be done if the stable fragment is adequate for restoration. Otherwise, extraction is required. Clinical follow-up is required after 1 week, 6–8 weeks, and 1 year. Radiographic follow-up is required after 6–8 weeks and 1 year as well. Monitoring is vital until eruption of the successors.

**Crown/root fracture (with pulp exposure)**: this type of fracture involves enamel and dentin and the pulp is exposed. The stage of development of root can be determined by the radiographic evaluation. Preservation of pulp vitality can be accomplished by partial pulpotomy using calcium hydroxide paste and reinforced

**Figure 4.**  *Crown fracture in primary dentition.* 

glass ionomer as liner and composite/compomer restorations. Unless there is a cooperation with the patient, extraction is an alternative treatment approach. Clinical follow-up is required after 1 week, 6–8 weeks, and 1 year. Radiographic follow-up is required after 6–8 weeks and 1 year as well.

**Root fracture**: the fracture involves the alveolar bone and may extend to adjacent bone leading to segment mobility and dislocation. Frequently, an occlusal interference is reported. Radiographic evaluation is required to assess the fracture line position. Treatment should be repositioning the displaced segment and splinting. Stabilization must be for 4 weeks. Monitoring the fracture line is essential. If there is no displacement, 1 week, 6–8 weeks, and 1 year clinical follow-up are required. After 1 year, radiographic evaluation should be repeated until eruption of the successors. If the traumatized tooth/teeth are extracted as treatment choice after 1 year, both clinical and radiographic examination are still required for monitoring successors.

 **Alveolar fracture**: the tooth is displaced, usually in a palatal/lingual or labial direction leading to mobility. Occlusal radiographic findings will reveal increased periodontal ligament space apically at its best. If there is no occlusal interference, the tooth is allowed to reposition spontaneously. If there is minor occlusal interference, slight grinding is indicated. When there is more severe occlusal interference, the tooth can be gently repositioned by combined labial and palatal pressure after the use of local anesthesia. In severe cases, when the crown is dislocated in a labial direction, extraction is indicated. Follow-ups are required as follows: 1 week and 2–3 weeks of clinical examination, and 6–8 weeks and 1 year clinical and radiographic examinations.

**Concussion**: clinically, tooth is sensitive to touch. There is no mobility or sulcular bleeding observed. Radiographic evaluation discloses no pathology as well. Observation is the only treatment option. Only clinical follow-up is required after 1 and 6–8 weeks.

**Subluxation**: an increased mobility is observed though the tooth is not displaced. There might be cervical bleeding. There is no abnormality in the radiographic evaluation. Occlusal radiography can screen possible root fracture and displacement. Observation is the only treatment option. Soft brushing and use of antibacterial agents is recommended. Only clinical follow-up is required after 1 and 6–8 weeks. Parents should be informed about an occurrence of possible crown discoloration. Unless a fistula is formed, monitoring is required.

**Extrusive luxation**: the tooth appears elongated due to its displacement out of its socket. Thus, it can be excessively mobile. Increased apical periodontal ligament space is disclosed in radiographic evaluation. For minor extrusion (<3 mm) in an immature developing tooth, careful repositioning or leaving the tooth for spontaneous alignment can be the treatment options. Extraction is indicated for severe extrusion in a fully formed primary tooth. Clinical follow-up is required after 1 week, 6–8 weeks, and 1 year. Radiographic follow-up is required after 6–8 weeks and 1 year as well. Parents should be informed about the possible occurrence of discoloration.

**Lateral luxation**: the tooth is displaced, usually in a palatal/lingual or labial direction and will be immobile. If there is no occlusal interference, the tooth is allowed to reposition spontaneously. For minor occlusal interference, slight grinding is indicated. If there is more severe occlusal interference, the tooth can be gently repositioned after the use of local anesthesia. If the crown is dislocated severely in a labial direction, extraction is indicated. Clinical follow-up is required after 1 week, 6–8 weeks, and 1 year. Radiographic follow-up is required after 6–8 weeks and 1 year as well.

**Intrusive luxation**: when the apex is displaced toward labial bone plate, the apical tip appears shorter than its contra lateral and the tooth is left for spontaneous repositioning. When the apex is displaced toward the permanent tooth germ, tooth appears elongated and must be extracted. Clinical follow-ups are required for 1 week, 3–4 weeks, 6–8 weeks, 6 months, and 1 year after, whereas radiographic

#### *Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150*

follow-up is 6–8 weeks and 1 year later. Clinical and radiographic monitoring is essential until eruption of the permanent successor.

**Avulsion**: clinical findings reveal that tooth is not in the socket; however, radiographic examination is required to confirm and not to overlook intrusion. Replantation of the avulsed teeth is not recommended. Clinical follow-ups are required for 1 week, 6 months, and 1 year after, whereas radiographic follow-up is for 6 months and 1 year after to monitor successors' eruption.

#### **5. Classification, definition, examination, and treatment planning in dental traumas**

#### **5.1 Hard tissue and pulp in permanent dentition**

**Enamel infraction**: no need to restore.

**Enamel-fracture**: it is a kind of uncomplicated crown fracture. An enamel fracture is a crown fracture limited to loss of enamel only. Small enamel fractures can be polished. Composite resin restoration may be preferred for more involved enamel fractures (**Figure 5**).

**Enamel-dentin fracture**: it is a kind of uncomplicated crown fracture. The tooth should be restored with composite resin. If the fragment is available, reattachment of fragment can be attempted (**Figure 6**).

**Figure 6.**  *Enamel-dentin and pulp fracture.* 

**Enamel-dentin-pulp fracture**: a complicated crown fracture involves enamel and dentin with pulp exposure. If the pulp exposure is visible, only a pink spot or bluish exposure site is cleaned and pulp-capping agent is applied. For larger pulpal exposures, partial pulpotomy and direct pulp-capping procedures are performed. Crown restoration method is the same as in uncomplicated crown fractures. Pulp capping and restoration should be performed at the same appointment, if possible (**Figures 6**–**8**).

**Crown fracture combined with luxation** results in ischemic changes that can lead to pulp necrosis. In these cases, there is no response to vitality tests. It is possible that the tooth has sustained a luxation injury and pulp necrosis (coagulation necrosis) is present. According to Dr. Tsukiboshi, for young patients under 18 years of age, regardless of pulp vitality, the restoration of the tooth should be done. Then, the patient should be followed for 1, 3, and 6 months to determine pulp vitality. After the waiting period, if pulp necrosis occurs, root canal treatment needs to be performed. Adult patients with a traumatized mature tooth with closed apex, after the confirmation of pulp necrosis in the first appointment, root canal treatment should be completed. Otherwise, pulpectomy may be performed (**Figures 9** and **10**).

**Crown-root fracture w/o pulp involvement**: the treatment is similar to the uncomplicated crown fracture. Firstly, necessity of pulp capping or partial pulpotomy is evaluated and then, rearrangement of the fragment is performed. If no need to pulp capping or partial pulpotomy, flowable composite resin may help to combine the fractured parts of the crown.

**Crown-root fracture with pulp involvement**: in these cases, the fractured segment accounts for the larger part of the crown and the fracture line has extended to the alveolar crest or below. These teeth may be seen too difficult to restore, but the location of the fracture line may help to decide the treatment procedure. If the location of the fracture line is located within the coronal third of the root, crown restoration is possible after the extrusion of the root. There are two ways for extrusion of the root: orthodontic or surgical.

**Figure 7.**  *Pulp capping after dental trauma.* 

**Figure 8.**  *Restoration during first appointment.* 

*Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150* 

**Figure 9.**  *Young patient's traumatized teeth with open apex.* 

**Figure 10.**  *Closure of apex of traumatized incisor after 1.5 years.* 

#### **5.2 Root fracture**

Root fracture is a fracture that involves cementum, dentin, and pulp. The fracture line may be horizontal, oblique, or vertical. But vertical root fractures may generally occur in endodontically treated teeth. For that reason, in this chapter, horizontally or obliquely fractured teeth will be considered.

Root fractures are classified as shallow or deep according to the location of fracture line. Root fracture is generally diagnosed by radiographs. Sometimes, displacement of the coronal segment is not present. So, the fracture line is easily missed by conventional radiographic techniques. Therefore, it is better to take the radiograph from different angles. Or cone beam computed tomography may be used to diagnose the root fractures. Otherwise, fracture lines may be discovered after several months.

While performing electric pulp testing, tooth may not be responding to it. In that cases, three possibilities may be thought: pulp tissue is severed at the fracture, there is no severance of the pulp, only the subluxation in the apical fragment or the pulp is severed, and the apical fragment is subluxated.

#### *5.2.1 Treatment planning of deep root fractures*

 The treatment of deep root fracture is simple: repositioning and fixation of coronal segment. Depending on how deep the fracture is and how mobile the coronal

segment is, fixation may be required for up to 3 months. Six months later, if there is no pulp necrosis, there will be no need to root canal treatment. In case of pulp necrosis, root canal treatment is done up to the fracture line [9, 10, 36–39].

#### *5.2.2 Treatment planning of shallow root fractures*

Restorative treatment can be very difficult. Sometimes extraction is the best treatment planning. If the extraction is the chosen treatment, the patient's age, oral condition, oral hygiene habits, the tooth's position, and the occlusion should be evaluated and then autotransplantation may be considered as an alternative plan.

#### **5.3 Subluxation**

Subluxation is clinically defined as injury to the periodontal tissues accompanied by bleeding from gingival sulcus, an increase in mobility but no dislocation of the tooth. There is sensitivity in percussion, and high mobility and bleeding are important criteria in diagnosis of subluxation. Electric pulp testing is important. In immature tooth, electric pulp testing will not respond, so re-test with electric pulp testing after a week is advised.

#### *5.3.1 Treatment planning*

In immature tooth: only follow-up is necessary. Root canal treatment is indicated in the presence of pulp necrosis. When there is a possibility of pulp necrosis, root canal treatment can be initiated without anesthesia.

 In mature tooth: follow-up visits without invasive treatment are advised 6–12 months after injury to allow pulp vitality to be recovered. In case of pulp necrosis, root canal treatment is indicated.

#### **5.4 Extrusive luxation**

Extrusive luxation results in damage to the periodontal tissues as the tooth is displaced in coronal direction. The periodontal tissue and the root are not completely separated, but the blood supply at the apex is disrupted. There is high mobility, bleeding, and electric pulp testing response is negative. Radiographically, there is widening in periodontal ligament space.

#### *5.4.1 Treatment planning*

Repositioning, fixation, and follow-up are the steps of treatment planning. Root canal treatment is avoided until pulp necrosis is confirmed. After confirmation of pulp necrosis, root canal treatment is indicated. In ımmature tooth, apexification and apexogenesis may be applicable.

#### **5.5 Lateral luxation**

Lateral luxation is an injury to the periodontal and alveolar supporting tissues that the tooth displaces laterally. The crown of the tooth is displaced palatally or lingually, and the tooth may be apically displaced with alveolar bone fracture on the labial side. The blood supply is completely disrupted at the apical side, but periodontal tissues have not been separated. Radiographically, the root shape and alveolar socket are not aligned. Sometimes, the traumatized teeth may be locked because of fracture on alveolar bone. This situation may be confused with ankylosis.

#### *Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150*

#### *5.5.1 Treatment planning*

Repositioning, fixation, and regular follow-up are the steps of treatment of lateral luxation. In fixation period, if alveolar fracture occurs, fixation period will take at least 3 months. Root canal treatment may be delayed until pulp necrosis has been confirmed. In young adults, apexification and apexogenesis may be treatment alternatives (**Figures 11** and **12**).

#### **5.6 Intrusive luxation**

Intrusion is a luxation injury that results in apical displacement of tooth. In some cases, alveolar bone fracture is also seen. In the diagnosis of ıntrusion, differential

**Figure 11.**  *Lateral luxated central incisor.* 

**Figure 12.**  *Splinting after lateral luxation.* 

#### *Trauma in Dentistry*

diagnostic criteria should be detected. If the tooth is intruded apically compared with adjacent teeth, intrusion should be thought. Reduced mobility may also be seen. Percussion sound is a metallic sound. There is no percussion sensitivity. If there is no clear periodontal ligament in radiograph, the intrusion should be suspected. CBCT images are important to differentiate the diagnosis of lateral or intrusive luxation (**Figure 13**).

#### *5.6.1 Treatment planning*

The healing of intruded tooth may be affected by some factors such as patient's age, root development degree, and depth of intrusion.

According to some studies, as age increases, the incidence of pulp necrosis, loss of marginal bone, and root resorption also increase. If intrusion is more than 7 mm, the more complications may be seen compared with those that are intruded less than 3 mm. Time between injury and treatment, type of fixation, and use of antibiotics may also affect the results.

**Figure 13.**  *An intruded central incisor.* 

**Figure 14.**  *An avulsed tooth.* 

#### *Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150*

Spontaneous re-eruption, orthodontic extrusion, and the surgical extrusion are the main options of intrusive luxation.

Dr. Tsukiboshim suggests spontaneous re-eruption when the depth of intrusion is shallow and the root is immature whereas surgical extrusion is indicated when the depth of intrusion is deep and the root is mature.

#### **5.7 Transient apical breakdown (TAB)**

TAB is a phenomenon linked to the repair processes in the traumatized pulp or pulp and periodontium of luxated mature teeth, which returns to normal when repair is completed. This phenomenon is described by Frances Andreasen in 1986.

#### **5.8 Avulsion**

Avulsion is defined as the condition that the whole tooth is completely separated from the supporting tissues.

 The success rate for an avulsed tooth after replantation depends on the vitality of periodontal ligament and attachment of the tooth (**Figure 14**) [9–12, 15, 24, 26, 27, 31, 36–40].

#### **6. Splinting**

#### **6.1 A splint may be necessary to stabilize the traumatized tooth after injury**

Dental splint is a rigid or flexible device or compound used to support, protect, or immobilize teeth that have been loosened, replanted, fractured, or subjected to certain endodontic surgical procedures (**Figures 15**–**17**).

#### *6.1.1 Flexible splinting assists in healing*

Characteristics of the ideal splint include:


11.provides patient comfort and esthetic appearance

12.easily accessible and easy to maintain oral hygiene.

#### *6.1.2 Types of splints*

Rigid splints: are used in cervical root fractures and alveolar bone fractures. Stainless steel wire >0.5 mm, direct composite resin or titanium ring splint (TTS), or direct composite resin reinforced with fiberglass ribbon can be used.

Flexible splints: allow for optimal pulp and periodontal ligament healing. Nylon, stainless steel wire <0.4 mm, nickel titanium wires up to 0.016 with composite resin, and glass ionomer cement splints are used.

**Figure 15.**  *Splint with ligature wire.* 

**Figure 16.**  *Arch wire and composite splint.* 

**Figure 17.**  *Composite resin splint.* 

*Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150* 

Compound splints: orthodontic bracket and wire are used as compound splint materials.

Instructions to patients having a splint placed include to:

1. taking a soft diet


Before beginning or continuing orthodontic treatment, traumatized teeth must be checked carefully.

It is recommended that even if there is a minor trauma to the teeth, one should wait for at least 3 months for orthodontic movement. Any kind of dental traumas to hard or soft dental tissues (e.g., minor concussions, subluxations, and extrusions) also requires a 3-month waiting period. For moderate to severe trauma/damage to the periodontium, at least 6 months of waiting period is recommended.

In root fracture cases, the tooth must not be moved for at least 1 year. If there is radiographic evidence of healing, those teeth may be moved successfully [15, 36–39].

#### **7. Regenerative endodontic treatment of necrotic immature permanent teeth due to dental trauma**

 An immature permanent tooth is defined by the British Society of Pediatric Dentistry as a tooth that is not fully formed, particularly the root apex. A vital pulp is necessary for the development and maturation of the tooth root [40]. Completion of the root development of the teeth and closure of the root apex takes place 2–3 years after the eruption of the teeth. If pulp necrosis occurs for any reason (trauma, caries, etc.) before root development is complete, the root development undergoes a standstill, so the root remains without closure. In such cases, root canal treatment is both inevitable and difficult to do, because the root canal is very large, and the dentin walls are very thin and fragile [16, 40–43].

As a result of trauma, opening of the pulp tissue into the oral cavity may lead to infection by reaching the pulp tissue of oral microorganisms [44]. However, damage to the vascular nerve pack at the apex of the severely traumatized tooth causes necrosis of pulp tissue [41, 44].

The completion of the root formation of immature teeth that have necrotic pulp, or the induction of a calcified barrier formation at the root apices is defined as apexification [21].

There are various difficulties in the treatment of immature necrosed young permanent teeth:


Until now, two apexification procedures for these teeth have been performed successfully. First of these procedures is conventional apexification inducing the formation of a barrier to apical calcification using calcium dihydroxide. Second is a one-step apexification method that provides production of an artificial apical barrier using mineral trioxide aggregate (MTA). In both the methods, constriction of apical foramen of an immature tooth has been shown [16, 38, 42, 43].

Traditional apexification treatment requires a large number of sessions, and problems with patient compliance may occur. Long-term use of calcium hydroxide may lead changing physical properties of dentin.

As a result of requirements of short-term completion of canal treatments, acceleration of healing and reduction of the sessions was sought response to one-step apexification with apex closuring by using MTA that has been on the agenda [25].

Advantages of MTA apexification over calcium hydroxide apexification are more such as reliable barrier formation, reduction in treatment time, requirement of lesser visits, hence reducing the root fractures and preventing the changing of physical properties of dentin. In addition, since the MTA is not cytotoxic, its biological properties are advantageous and induce tissue repair.

Despite the popularity among clinicians, there are disadvantages of the apexification technique compared with MTA:


However, the risk of development of cervical root fractures remains high after apexification treatments [28].

The disadvantages of traditional apexification treatments have led the researchers to quest an alternative treatment approach that restores the function of the pulp dentin complex and persists its development. This quest led to arise of regeneration and regenerative endodontic treatment.

In biology dictionaries, regeneration is defined as the regrowth by an animal or plant of an organ, tissue, or part that has been lost or destroyed [21].

Regenerative endodontics is one of the most exciting new developments in endodontics. The current (2016) American Association of Endodontists' Glossary of Endodontic Terms defines regenerative endodontics as "biologically-based

#### *Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150*

procedures designed to physiologically replace damaged tooth structures, including dentin and root structures, as well as cells of the pulp-dentin complex" [21].

Regenerative endodontic procedures, a new approach to preventing tooth loss, aim to restore the damaged pulp and dentin structures, create a new pulp tissue in the canal, and provide root maturation [16, 28, 38, 43].

Seeking to find the ideal treatment method within the regenerative endodontics continues. The most studied methods in this area are: root canal revascularization, stem cell therapy, pulp implants, scaffold implants, injectable scaffold applications, three-dimensional cell software, and gene therapy. However, only the root canal revascularization could be used clinically in the treatment of traumatized necrotic young permanent teeth [28].

 Revascularization term is used to indicate the restoration of blood flow to the necrotic pulp cavity. Despite the fact that pulpless teeth can sustain their presence in the mouth for a long time after successful endodontic treatment, the viability of the dental pulp offers many advantages, including the formation of reparative dentin, the completion of apical closure, and the development of dentin walls. Via the root canal revascularization, the pulp tissue is regenerated and the permanence of the tooth vitality is ensured [28, 38].

There are also negative aspects such as the fact that some dental pathologies, such as progressive decay, cannot be recognized by patients due to the loss of sensitivity to environmental changes by pulpless teeth.

In addition, the elimination of the negative consequences of traditional root canal treatment procedures is the reason why revascularization is preferred in the treatment of necrotic traumatized young permanent teeth.

 At the basis of revascularization lies the rationale that "new cells can develop in the presence of sterile tissue matrix and pulp vitality can be restored," because when dental canal infection is under control, it becomes a necrotic, avulse tooth condition with sterile pulp cavity. Regeneration in the apical tissues after the avulsion and replantation suggests regeneration may occur in the pulp tissue of a necrotic and infected tooth [16, 43, 45].

In the revascularization method, after the necrotic root canal is totally disinfected, it is aimed to provide a fibrin matrix with the blood clot formed by the bleeding from the tooth apex provided by the over instrumentation. Revascularization is observed through the new cell development via the differentiation of few stem cells preserved vital, in this provided sterile matrix [16, 43].

Hargreaves et al. recommended three major components of pulp regeneration called triad of regenerative endodontics:


Stem cells are nondifferentiated cells that are capable of differentiating themselves into specialized cells, which can be transformed into many different cell types, when appropriate conditions are achieved within the body or in the laboratory. They are self-renewing and thus can generate any tissue for a lifetime unlike other progenitor cells [21].

Stem cell sources that play a role in the regeneration and root development of pulp tissue in the treatment of revascularization include dental pulp cells that maintain the viability of the root canal, stem cells originating from the apical papilla, and periodontal ligament [16, 19].

Blood clot is a very rich source of growth factors and has an important role in the differentiation, maturation, and regeneration of fibroblast, odontoblast, and cementoblast [23].

#### **7.1 The importance of root canal disinfection in revascularization treatments**

Absence of bacteria in the root canal is critical for successful revascularization therapy, because the development of new tissue stops when it encounters bacteria in the canal cavity.

The most effective root canal disinfection method is provided by drugs applied to the root canal in addition to chemical irrigation.

However, a good preparation in open apex tooth and the use of cytotoxic antiseptics may remove pulp cells that are well fed and viable in the apical region. Removal of these tissues means removal of cells with the potential to convert to pulp and dentin [16, 41, 43, 46].

Sato et al., who applied the triple antibiotic paste in vitro for the first time, reported that triple antibiotic paste is effective in the treatment of dentin infected by *Escherichia coli* [46].

#### **7.2 Patient selection criteria for revascularization treatment**

 The success of the treatment is based on the right case selection. No studies have been conducted on the success of revascularization therapy in individuals with genetic disease, severe medical disease, or poor immune system. Therefore, revascularization therapy procedures should be limited to systemically healthy people.

Revascularization therapy is not suitable for individuals allergic to triple antibiotics used in the canal.

 It is not indicated in patients who cannot adapt or participate in the treatment process due to being a long-term and follow-up procedure, and in individuals who are fearful or uncooperative [42, 45, 47].

#### **7.3 Tooth selection criteria for revascularization treatment**

 First of all, the tooth to be treated should be necrosis. Other regenerative therapies are considered such as pulp capping or partial pulpotomy with regenerative medicaments in teeth with vital pulp and partial pulpitis.

 The presence of radiolucency in the periapical region as well as vitality tests has long been used as a determining factor. In both cases, vital pulp cells and apical papilla can still be present in the canal and apex.

Another criterion is the presence of infection. However, as a hypothesis, the presence of long-term infection adversely affects the survival of the pulp tissue and stem cell continuity, and makes it difficult to control the infection.

Since apex opening greater than 1 mm increases success, it should be preferred in immature young permanent teeth. Although a very few researchers recommend to expand the apex with a hand piece in the teeth with closed apex having less than 1 mm apex opening, but in the guidelines, the indication is limited to the open apex teeth.

Furthermore, the loss of coronal tissue in the teeth that will be treated with revascularization should not exceed the size for allowing it to be restored, and tissue damage should not be large, requiring to be made post/core [16, 41–43, 47].

#### **8. Procedures in regenerative endodontics**

 An informed consent document must be taken before the treatment. This document should include the informations of complications such as tooth coloration or treatment failure, side effects such as pain or infection that may be able to emerge, two (or more) appointments will be needed, and what type of antibiotics will be used. Also, besides the nontreatment option, the patient must be informed about the tooth extraction (when deemed the tooth is nonsalvageable), and calcium hydroxide and MTA apexifications as the alternative treatments of revascularization. Following the consent document signing, treatment can be commenced [16, 18, 19, 25, 28, 38, 41–44, 46–49].

#### **8.1 First appointment**

Under local anesthesia and rubber dam isolation, an access cavity is prepared for the treatment. Each root canal opening is expanded to facilitate the placement of the medicament. The remaining root canal is not instrumented.

 Copious, passive irrigation is made with 20 ml of 1.5% sodium hypochlorite (NaOCl), for 5 minutes to each canal, followed by a sterile saline solution or EDTA (20 ml for each canal, 5 minutes). It is important to maintain the vitality of stem cells in the apical tissues. Therefore, an irrigation system such as needle with closed end and side vents is used to minimize the odds of extrusion of irrigant agents into the periapical area. Also, the irrigation needle should be positioned approximately 1 mm from the root end to minimize cytotoxicity to stem cells in the apical tissues.

After sufficient irrigation, the canals are gently dried with sterile paper points.

Calcium hydroxide, or low concentration of triple antibiotic paste, can be used to fill the canals.

A triple antibiotic paste is an antibiotic mix made from tablets of ciprofloxacin, metronidazole, and minocycline in a ratio of 1:1:1. For preparation, after removal of the coatings on the tablets, the tablets are pulverized and mixed in a 1:1:1 ratio in a sterile saline to form a paste-like consistency.

Triple antibiotic paste has been associated with tooth discoloration; therefore, if it is used, to minimize risk of staining, pulp chamber is sealed with a dentin bonding agent and ensure that it should remain below cemento-enamel junction (CEJ).

For minimizing the coronal staining, modified triple antibiotic paste obtained by adding another antibiotic (e.g., clindamycin, amoxicillin, and cefaclor) instead of minocycline, or minocycline-free double antibiotic pat, may also be used.

After delivering the paste into the canals via syringe, a sterile cotton pellet is placed into the canal below the CEJ and the cavity is sealed with temporary filling so as not to allow microleakage.

#### **8.2 Second appointment (1–4 weeks after first visit)**

In the second appointment, 1–4 weeks after the first visit, the response of the initial treatment is evaluated. If the clinical signs/symptoms persisted, the first appointment treatment procedures are repeated with antimicrobials, or alternative antimicrobials.

If the tooth has become asymptomatic, the second session is started through the anesthesia with 3% mepivacaine free of vasoconstrictor.

After the tooth is isolated with rubber dam, the temporary filling and cotton pellet are removed.

#### *Trauma in Dentistry*

Following the removing of the paste from the canals by irrigation with 20 ml of 17% EDTA, the canals are dried with sterile paper points.

Bleeding into canal system to the level of CEJ is created by 2 mm over-instrumenting through rotating a precurved K-file. The using of platelet-rich plasma (PRP), platelet-rich fibrin (PRF), or autologous fibrin matrix (AFM) has been considered as the alternatives to create a blood clot, especially when bleeding into the canal cannot be achieved.

Bleeding is stopped at a level allowing for 3–4 mm of restorative material. In order to ensure the formation of blood clot, place a sterile cotton pellet for 3–4 minutes upon the bleeding. If it is necessary, placing a resorbable matrix (e.g., CollaPlug™, Collacote™, and CollaTape™) over the blood clot is applicable.

For stabilizing the white MTA that is used as a capping material, 3–4 mm layer of light-curing glass ionomer is flowed gently over it. Because the MTA has been associated with discoloration, it should be placed just below the level of the CEJ, over the blood clot. If there is an esthetic concern, alternative materials of MTA like bioceramics or tricalcium silicate cements should be considered.

Finally, the access cavity is restored with a suitable restorative material [16, 18, 19, 25, 28, 38, 41–44, 46–49].

#### **8.3 MTA as a coating material**

MTA, with quite good physical properties in terms of covering and sealing, is one of the most ideal coating materials to be used for the hermeticity of coronary closure.

In addition, the application with glass ionomer resin increases its covering properties and durability.

To allow more root growth, the MTA should be 1–2 mm thick below the CEJ.

Placing the MTA on the formed clot is a technically difficult procedure. Care should be taken during condensation, because the material can be moved from the CEJ to the apical point [16, 43].

#### **8.4 Follow-up, goals, and success in revascularization treatment**

Appointments are given to the patient at intervals of 3–6 months, and root formation is monitored clinically and radiographically.

The success of pulp revascularization treatment depends on three elements: root canal disinfection, the presence of a scaffold (blood clot), and hermetic coronary filling [38, 45].

The degree of success of regenerative endodontic procedures is largely measured by the degree to which primary, secondary and tertiary goals are achieved.

Primary goal: elimination of symptoms and healing of bone tissue.

 Secondary goal: the increase in the thickness and/or the length of the root walls (although it is a desirable condition).

Tertiary goal: positive response to vitality test (indicates the presence of a more organized vital pulp tissue).

Five different types of responses to revascularization treatments are available: Type 1—thickening and root development of canal walls

Type 2—the root of the root end is blunt and closed and the root growth is stopped

Type 3—root development continues, but the apex remains open

Type 4—common calcification in canal cavity

Type 5—hard tissue barrier formation between root apex and coronal MTA.

*Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150* 

#### **Figure 18.**

*A necrotic, immature, 21 numbered teeth, due to dental trauma from a year ago.* 

#### **Figure 20.**

*Third month of the treatment: the lateral walls were thickened by the continued growth of dentin/hard tissue and the root length was increased.* 

#### *Trauma in Dentistry*

If the treatment becomes success, in clinical and radiographical follow-ups, there should be no pain or swelling, apical radiolucency should be disappeared (usually observed 6–12 months after treatment), the root canal walls should be thickened (observed before the increase of the root length between 12 and 24 months), and the root length should be prolonged. Pulp should respond positively to vitality tests.

 If there is no evidence of recovery, if the fistula does not disappear, and pain and swelling persist or no root growth is observed within 3 months, apexification with calcium hydroxide or MTA can be tried.

If pulp necrosis develops afterward, traditional endodontic treatment protocols should be performed [16, 18, 19, 25, 28, 38, 41–44, 46–49].

#### **8.5 The advantages of revascularization treatment**

Revascularization can be completed in a single session after the infection is controlled, and there is no need for repeated sessions as in the treatment of calcium hydroxide. This is very economical.

The greatest advantage is that it can regenerate the vitality of the tooth and maintain the root development.

The lateral walls are supported by the continuation of the dentin/hard tissue deposition, and the durability of the root is increased [16, 18, 19, 25, 28, 38, 41–44, 46–49] (**Figures 18**–**20**).

#### **Author details**

Asli Topaloglu Ak\*, Didem Oner Ozdas, Sevgi Zorlu and Pinar Kiymet Karataban Department of Pediatric Dentistry, Dentistry Faculty of Istanbul Aydin University, Istanbul, Turkey

\*Address all correspondence to: asliak@aydin.edu.tr

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Dental Traumatology in Pediatric Dentistry DOI: http://dx.doi.org/10.5772/intechopen.84150* 

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Section 5

Mandibular Fractures

Section 5
