Management of Luxation Injuries - Pediatric & Preventive Dentistry Exam Answer

Classification of Luxation Injuries

Luxation injuries are the most common traumatic dental injuries (TDIs) in the primary dentition, while crown fractures are more common in the permanent dentition. (IADT 2020 General Introduction, Levin et al., Dent Traumatol. 2020;36:309-313)

Key Principles Applicable to Both Dentitions

• History: time, place, mechanism of injury
• Radiographic assessment (periapical/occlusal views)
• Sensibility/vitality testing (cautiously in children)
• Check for associated injuries (alveolar fracture, soft tissue)
• Non-accidental trauma must always be considered - over 50% of child abuse cases involve craniofacial and dental injuries (Tintinalli's Emergency Medicine)

• Use flexible/functional splints (0.4 mm TTS wire or similar)
• Duration varies by injury type and dentition
• Rigid splinting is no longer recommended as it impairs PDL healing

Management in the PERMANENT Dentition

1. Concussion

• No immediate treatment needed
• Soft diet for 1-2 weeks
• Monitor pulp vitality at follow-up (1 week, 6-8 weeks, 1 year)
• Risk of pulp necrosis (more common in mature roots)

2. Subluxation

• No repositioning needed
• Flexible splint for 2 weeks may aid patient comfort
• Soft diet; oral hygiene maintenance with 0.12% chlorhexidine rinse
• Monitor pulp vitality closely; pulp necrosis occurs in up to ~15% of cases

3. Extrusive Luxation

• Reposition gently by digital pressure into socket as soon as possible
• Apply flexible splint for 2 weeks
• Soft diet + chlorhexidine rinse
• Antibiotics: Doxycycline (adults) or Penicillin V (children)
• Tetanus prophylaxis if indicated
• Follow-up: 2 weeks, 4 weeks, 3 months, 6 months, 1 year, 5 years
• Prognosis: Generally favorable; pulp necrosis possible especially in mature teeth

4. Lateral Luxation

• Reposition (may require local anesthesia): apply finger pressure to free the crown from bony lock, then reposition palatally/lingually
• Apply flexible splint for 4 weeks
• Teeth with immature apices may revascularize; mature apices almost always develop necrosis requiring RCT
• Monitor closely; if discoloration or apical pathology, initiate endodontic treatment

5. Intrusive Luxation

• Mature teeth with intrusion almost always develop pulp necrosis - endodontic treatment with calcium hydroxide should be initiated within 2-3 weeks to prevent inflammatory resorption
• A 2024 retrospective study (PMID 38234011) confirmed that root immaturity and lesser depth of intrusion significantly improve spontaneous re-eruption rates

Key 2020 IADT Change for Intrusion (Important for Exams)

Management in the PRIMARY Dentition

1. Concussion

• No treatment required
• Dietary advice; monitor for colour change or mobility at follow-up visits

2. Subluxation

• No active intervention required
• Soft diet advice; follow-up at 1 week, 3-4 weeks, 6-8 weeks, 1 year
• Monitor for pathological mobility or discoloration

3. Extrusive Luxation

• Mild (< 3 mm): Reposition and splint OR allow passive repositioning
• Severe (> 3 mm) or near exfoliation: Extract the tooth
• Do not persist with a tooth at high risk of aspiration

4. Lateral Luxation

• Conservative approach (2020 IADT Update): If no occlusal interference and tooth not severely displaced - observe and allow spontaneous repositioning
• If occlusal interference present: reposition gently or extract
• The 2020 guidelines moved away from reflexive repositioning/splinting of primary lateral luxations toward watchful waiting - a key exam difference from older guidelines

5. Intrusive Luxation

• Most common luxation injury in the primary dentition
• 90% of intruded primary teeth spontaneously re-erupt within 2-6 months
• Allow spontaneous re-eruption if apex directed away from permanent tooth germ (buccal direction on radiograph)
• Extract if:
  • Apex directed toward/against the permanent tooth germ (radiographic finding)
  • Tooth intruded >3 mm with apex toward successaneous tooth
  • Severe intrusion (tooth not visible)
• Do NOT force extrusion; this risks damaging the permanent tooth germ

Primary Dentition - Avulsion (for completeness)

• Do NOT replant primary teeth - replantation risks damage to permanent tooth germ, risk of ankylosis, aspiration risk, and poor prognosis
• Inform parents about possible effects on developing permanent successor

Splinting - Updated Evidence (2020-2025)

• Concussion/Subluxation: 2 weeks maximum (or no splint)
• Extrusive luxation: 2 weeks
• Lateral luxation: 4 weeks
• Intrusive luxation (surgically repositioned): 4 weeks
• Alveolar fracture: 4 weeks

• Dos Santos Fernandez et al. (2023, Systematic Review, PMID 36930443): Found splinting in the primary dentition has high success rates for root fractures, but benefits for lateral luxation alone are unclear. Only low-quality retrospective evidence exists. The review concluded splinting is best justified for root fractures in primary teeth.
• Kumari et al. (2025, Systematic Review, PMID 41026553): Reviewed splinting after replantation of avulsed permanent teeth. Found trends supporting flexible splints and shorter durations for better periodontal and pulpal outcomes, but evidence was graded very low (GRADE). Current practice should follow IADT guidelines for flexible/short-term splinting.

Follow-Up Protocol (IADT 2020)

Complications to Know

• Pulp necrosis: Most common after lateral and intrusive luxations in mature teeth; managed with RCT ± calcium hydroxide dressing
• Pulp canal obliteration (calcific metamorphosis): Yellow discoloration; more common after subluxation in immature teeth; monitor, RCT only if infection develops
• Inflammatory root resorption: Rapid, life-threatening to tooth; calcium hydroxide dressing urgently required
• Replacement resorption (ankylosis): Tooth fuses to bone; detected by metallic percussion sound; infraocclusion in growing jaws
• Disturbance to permanent tooth germ (primary dentition injuries): White spots, hypoplasia, dilaceration, ectopic eruption, or impaction of permanent successor

Prevention of Dental Luxation Injuries

1. Mouthguards: Custom-fitted mouthguards significantly reduce dental trauma risk in contact sports; highest protection vs. stock or boil-and-bite types
2. Early orthodontic intervention: Increased overjet (>3 mm) is a major risk factor for maxillary incisor trauma - class II correction and lip competence improvement reduces risk
3. Supervision during toddler years: Peak incidence at 2-4 years during walking development
4. Sports dentistry programs: School-based education on trauma first aid
5. Parent/first-responder education: The Tooth F.I.R.S.T Aid acronym (Find, Inspect, Rinse, Store, Time - seek care) has been proposed as a community education tool (Mathew et al., 2025, PMID 40022491)
6. Trauma registers: The IADT 2020 introduced a core outcome set for reporting TDIs - standardises research and clinical records

Summary Table: Primary vs. Permanent Dentition Luxation Management

Key References

• Bourguignon C, et al. IADT Guidelines: Fractures and Luxations. Dent Traumatol. 2020;36:315-330 [PMID 32475015]
• Day PF, et al. IADT Guidelines: Injuries in the Primary Dentition. Dent Traumatol. 2020;36:343-359 [PMID 32458553]
• Philip N, Nazzal H, Duggal MS. Critical appraisal of 2020 IADT Guidelines. Dent Traumatol. 2023 [PMID 37408436]
• Dos Santos Fernandez M, et al. Splinting in primary dentition trauma. Systematic Review. Eur Arch Paediatr Dent. 2023 [PMID 36930443]
• Kumari B, et al. Splinting in replanted avulsed permanent teeth. Systematic Review. J Indian Soc Pedod Prev Dent. 2025 [PMID 41026553]
• Tintinalli's Emergency Medicine: A Comprehensive Study, Ch. 124 (Pediatric Dental Trauma section)
• Rosen's Emergency Medicine: Concepts and Clinical Practice, Ch. 56 (Luxation and Alveolar Fractures section)

1. Splinting Duration and Type (Subluxation/Extrusion/Lateral Luxation)

Kumari et al. (2025) in a systematic review (J Indian Soc Pedod Prev Dent) confirmed trends favouring flexible splints over rigid, and shorter durations for better periodontal and pulpal outcomes following replantation. However, GRADE evidence was rated very low, reinforcing that IADT guidelines remain the best available consensus. [PMID 41026553]

2. Splinting in Primary Dentition Luxations

Dos Santos Fernandez et al. (2023) - systematic review (Eur Arch Paediatr Dent) - found no clear benefit of splinting for lateral luxation in primary teeth, though it may still be recommended. Splinting showed better outcomes primarily for root fractures in primary teeth. Evidence quality was low (only 3 retrospective studies). [PMID 36930443]

3. Intrusive Luxation - Spontaneous Re-eruption vs. Intervention

Singhal et al. (2024) - retrospective analysis (Dent Traumatol) - confirmed that root immaturity and lesser depth of intrusion are significant predictors of successful spontaneous re-eruption and fewer healing complications, supporting the 2020 IADT conservative wait-and-watch approach for immature teeth. [PMID 38234011]

4. Critical Appraisal of 2020 IADT Changes (Advanced/MCQ-Proof Point)

Philip, Nazzal & Duggal (2023) - Dent Traumatol - critically appraised the 2020 IADT updates and noted that while the shift to more conservative management of primary dentition luxations and changes to intrusion management in immature teeth are clinically logical, the supporting evidence base is not yet robust. They highlighted that recommendations for some injuries are still largely expert consensus rather than high-quality RCT evidence. [PMID 37408436]

5. Prevention / Mouthguards Section

Mathew et al. (2025) proposed the Tooth F.I.R.S.T Aid acronym (Find, Inspect, Rinse, Store, Time) as a community-level first-responder education tool aligned with updated IADT guidelines, emphasising the role of public awareness as a preventive strategy at the tertiary level. [PMID 40022491]

Quick Reference Card

Latest Evidence to Add for Management of Avulsion - Where & What to Quote

1. Storage Medium / Transport Medium

Zhang et al. (2021) conducted a network meta-analysis of 20 RCTs comparing 10 storage media (Front Med, Lausanne). They found propolis ranked highest in preserving PDL cell viability, superior to HBSS and milk. HBSS remained superior to milk, saline and water. Coconut water performed comparably to ORS/HBSS. Aloe vera gel (AVG) ranked lowest. The practical recommendation remains: propolis > HBSS > ORS/coconut water > milk when available. [PMID 34708058]

2. Extra-Oral Dry Time and Survival

Ceyhan & Kirzioglu (2025) in a 20-year retrospective hospital-based study (J Oral Sci) found that retention was significantly shorter for teeth stored dry, and the most common healing complications were ankylosis (70.6%) and inflammatory root resorption (54.9%). Only 17 of 51 replanted and followed teeth were retained long-term, confirming the guarded prognosis of replantation especially with delayed/dry storage. [PMID 41093571]

Ozturk Sheikholaemeh & Sengul (2025) in a retrospective study of 60 replanted teeth (Dent Traumatol) reported a 5-year Kaplan-Meier survival rate of only 47.5%. Replacement resorption affected 66.7% of teeth. Inflammatory resorption was NOT observed in teeth replanted within 1 hour of injury. Root maturity and gender significantly affected prognosis (mature teeth and males had better survival, p<0.05). [PMID 39754382]

3. Splinting After Replantation

Kumari et al. (2025) - systematic review (J Indian Soc Pedod Prev Dent) of 708 participants/975 avulsed teeth - found trends supporting flexible splints and shorter durations (2 weeks per IADT) for better periodontal and pulpal outcomes, but GRADE evidence was rated very low. No one splint type showed statistically significant superiority. Current IADT guidelines for flexible, short-duration splinting represent the best available consensus. [PMID 41026553]

4. Adherence to IADT Guidelines in Clinical Practice

Zerman et al. (2026) - scoping review of 92 studies (Eur J Paediatr Dent) - found that despite IADT guidelines being widely known, clinicians still show greater alignment with the 2012 guidelines even after 2020 updates. Long-term failure rates for replanted teeth ranged from 55% to 96% across studies. Key challenges persist: ankylosis, root resorption, and inadequate long-term follow-up protocols. The review called for future guideline revision to address prosthetic planning and medico-legal clarity for failed replantations. [PMID 40654128]

5. Delayed Replantation - Regenerative Endodontic Procedures (REPs)

For Immature Teeth (Open Apex) - Key Emerging Evidence

Sheng et al. (2025) - retrospective study (Int J Paediatr Dent) of 17 delayed replanted immature permanent teeth treated with REPs - found 47.1% had successful REP + periodontal healing. Periapical lesion healing was observed in 88.2% of cases, but only 41.2% showed continued root development. Importantly, teeth with continued root development had a higher rate of functional healing (85.7% vs 30%). REPs were deemed a reliable option for treating delayed replanted immature teeth but outcomes remain unpredictable. [PMID 39245892]

Kaufman et al. (2026) - observational study (Dent Traumatol) of 8 avulsed immature teeth with delayed replantation and external inflammatory root resorption (EIRR) - found that Regenerative Endodontic Treatment (RET) using triple antibiotic paste + PRF (platelet-rich fibrin) arrested EIRR and converted it to the slower replacement resorption. Crucially, 7 of 8 teeth maintained favorable eruption patterns without infraposition despite progressive replacement resorption. RET with PRF was proposed as the most effective endodontic approach after avulsion in growing patients as it preserves alveolar ridge height and prevents ankylosis-associated infraposition. [PMID 40714997]

6. Cell-Based / Tissue Engineering Approaches (Future Directions / Research Advances)

Chew et al. (2022) - systematic review (Tissue Eng Part B) - evaluated cell-based therapies for delayed replantation in animal models. PDL-derived cells showed the best outcomes, increasing PDL healing and reducing replacement root resorption and ankylosis. While currently only preclinical, this represents a paradigm shift from chemical root conditioning toward biological augmentation of the PDL. Clinical translation is pending standardization of cell delivery protocols and allogeneic cell use. [PMID 33593127]

7. Endodontic Management After Replantation - MTA

Kharkova & Korolenkova (2024) highlighted the role of mineral trioxide aggregate (MTA) as an alternative to calcium hydroxide for managing dental trauma complications including apexification in immature replanted teeth. MTA's superior sealing properties and biocompatibility make it a preferred material in contemporary management of post-avulsion endodontic complications in children. [PMID 39171345]

Master Reference Card for Avulsion

1. Zhang et al. 2021 - propolis > HBSS > milk (storage media NMA)
2. Kaufman et al. 2026 - RET + PRF prevents infraposition after delayed replantation
3. Zerman et al. 2026 - 55-96% long-term failure rate; 2020 IADT not yet widely adopted in clinical reporting