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This case report demonstrates the possibility of functional and aesthetic rehabilitation using an interdisciplinary approach in a child following avulsion of a tooth. Autotransplantation after the development of calcific metamorphosis of the pulp and acute apical periodontitis provided satisfactory repair after root canal treatment. A 7-year-old white boy avulsed the right maxillary central incisor (tooth 11). The extra-alveolar time exceeded 60 minutes, and this triggered external replacement resorption of the avulsed tooth. At 11 years of age, the child underwent tooth autotransplantation. After 4 years of follow-up, intraoral clinical and radiographic examination led to the diagnosis of calcific metamorphosis of the pulp and acute apical periodontitis. The patient had minimally invasive root canal treatment, orthodontic treatment and esthetic rehabilitation with a porcelain crown. Control periapical radiography and tomography of the autotransplanted tooth after 7 years revealed bone repair in the periapical region. This case report indicates that tooth autotransplantation can be used to replace anterior teeth after avulsion followed by replacement resorption. Interdisciplinary management helped to maintain the esthetics and function of the rehabilitated area.

Background/aims Traumatic dental injuries (TDI) occur frequently and may result in pulp sequelae. This includes pulp necrosis with infection, pulp canal obliteration and root resorption. The aim of this study was to assess the prevalence and risk factors of pulp sequelae after TDI among Norwegian adolescents. Material and methods A retrospective longitudinal study, including historical clinical data, was conducted with 16-year-old pupils in western Norway. All first-grade pupils, born in 1997 (n = 5184), attending public high schools, were invited to participate and to respond to an electronically administered closed-ended questionnaire (response rate 39.6%, n = 2055). Consent was given to access the dental records in the Public Dental Health Service in Hordaland, where information regarding TDI (diagnosis and treatment) and radiographs were interpreted. Only TDIs to anterior teeth were recorded (canine to canine in the maxilla and mandible). Outcome variables of TDI were registered and analysed using logistic regression, Kaplan-Meier survival estimates and log-rank test. Results The prevalence of TDI in the sample population was 16.4% (338 pupils), with a total of 637 teeth involved. The number of included teeth for analysis was 571 (90.5%). The prevalence of pulp necrosis with infection was 7.5%. Moderate and severe TDI was associated with a higher frequency of pulp necrosis with infection. Pulp canal obliteration and root resorption were found in 2.8% and 2.3% of teeth with TDI, respectively. Dental hard tissue injuries were more prone to the development of pulp necrosis than luxation injuries and combination injuries. The relationship between root development stage and development of pulp necrosis with infection was not statistically significant. Conclusions Occurrence of different pulp sequelae among teeth affected with TDI was low. Moderate and severe TDI were more at risk of developing pulpal complications and hard tissue injuries were at higher risk of developing pulp necrosis with infection.

Background/aims In epidemiological studies, traumatic dental injuries in children are usually determined from clinical signs or parents' reports. Radiographs are used in dental trauma centers but not in field surveys. The aim of this study was to evaluate the proportion of patients who present with radiographic evidence of trauma without any clinical signs of a history of TDI. Methods The prevalence of traumatic dental injuries was assessed from the records of 674 preschool children at their first visit to a private dental practice. Evidence of the history of traumatic dental injuries was based on clinical and radiographic signs. Clinical signs consisted of enamel fracture, crown fracture with dentin exposure (with or without pulp exposure), internal coronal discoloration, and the presence of a draining sinus. Radiographic signs were as follows: root fracture, pulp canal obliteration, tube-like mineralization, internal resorption, arrested dentin deposition, external inflammatory root resorption, and a periapical radiolucency. Results Of the 674 children, 408 (60.5%) presented with clinical evidence of traumatic dental injuries. This included 195 (28.9%) with enamel fracture as the sole sign. Seventeen (2.5%) had radiographic signs of traumatic dental injuries without any clinical evidence of trauma, increasing the prevalence of traumatic dental injuries by 2.5-63.0%. Fifteen of these were pulp canal obliteration, one root fracture, and one with arrested dentin deposition. Clinical signs of traumatic dental injuries without radiographic evidence of trauma were present in 275 (40.8%) patients. Conclusion Traumatic dental injuries based on both clinical and radiographic evidence are more prevalent than when based on clinical examination only.

Aim To present a new treatment approach for teeth with pulp canal calcification (PCC) which require root canal treatment. Case A 15-year-old male patient presented with pain of his upper right central incisor. The tooth showed signs of apical periodontitis. Due to PCC, location of the root canal was judged to be difficult and associated with a high risk of perforation. A cone beam computed tomography (CBCT) and an intra-oral surface scan were performed and matched using software for virtual implant planning. After planning the position of the drill for root canal location, a virtual template was designed, and the data were exported as an STL file and sent to a 3D printer for template fabrication. The template was positioned on the anterior maxillary teeth. A specific drill was used to penetrate through the obliterated part of the root canal and obtain minimally invasive access to the apical part. The root canal was accessible at 9 mm distance from the apex. Further root canal preparation was carried out using an endodontic rotary instrumentation system. After an interappointment dressing for 4 weeks, the root canal was filled with vertically condensed gutta-percha using an epoxy sealer. The access cavity was restored with a composite material. After 15 months, the patient was clinically asymptomatic with no pain on percussion. The radiograph showed no apical pathology. Conclusions The presented guided endodontic approach seems to be a safe, clinically feasible method to locate root canals and prevent root perforation in teeth with PCC.

Background Avulsion of permanent teeth is one of the most serious dento-alveolar traumatic injuries. Pulp canal obliteration (PCO) is one of the consequences after replantation of avulsed immature teeth. The aim of this systematic review was to determine when calcification following replantation of an avulsed immature tooth begins and to evaluate the prevalence of PCO in these cases. Materials and methods Electronic database MEDLINE via Ovid, PubMed, Cochrane, and Web of science databases were searched. Hand searching was performed through reference lists of endodontic and trauma textbooks, endodontic and trauma-related journals, and relevant articles from electronic searching. Pooled data from the selected articles were analyzed for prevalence of healing and PCO as well as mean first evidence of PCO. Results Pulp healing after replantation of immature teeth occurred in 32.9%, while pulpal necrosis occurred in 67.1% of teeth. PCO was the most frequent outcome of pulpal healing as it occurred in 96% of healed pulps. First evidence of obliteration was observed from 3 to 14 months with mean time of 9.5 months (95% CI = 4.5–14.5 months). Conclusions PCO is considered the mechanism by which the pulp heals after replantation of avulsed immature permanent teeth. PCO is very fast and can be recognized radiographically during the first year from the onset of the trauma.

Aim This study aimed to investigate the influence of the radicular maturity level of primary teeth on the sequelae of traumatic dental injury (TDI). Materials and methods A longitudinal retrospective study that collected data from dental records and radiographs of patients with TDI in one or both maxillary primary central incisors was conducted. Sequelae such as crown discoloration, pulp canal obliteration (PCO) and inflammatory root resorption (IRR) were evaluated during a 12- to 18-month follow-up period after the trauma. Results Of the 132 patients included in the study, 103 (78%) had luxations and 29 (22%) had dental fractures. At the initial postinjury examination, 12 teeth (9.1%) were found to have immature roots, 107 (81.1%) had closed apexes and 13 (9.8%) had visible root resorption. Inflammatory root resorption occurred mostly in traumatized teeth that presented with physiological root resorption at the moment of trauma (P = 0.004). The frequency of PCO was higher in teeth with a closed apex at the moment of the injury (P = 0.026). There was also an association between the type of injury and the occurrence of crown discoloration (P = 0.008) as well as between the type of injury and the development of PCO (P = 0.001). Conclusions The occurrence of TDI sequelae can be determined by the type of injury as well as by the radicular maturity level of the primary teeth at the moment of injury.

Intrusive luxation is a kind of traumatic injury characterized by an axial displacement of the tooth toward the alveolar bone. Its main causes are bicycle accidents, sports/recreational activities, and falls or collisions. Treatment strategies include waiting for the tooth to return to its position, immediate surgical repositioning, and repositioning through dental traction by orthodontic devices. In order to decide which treatment to follow, the degree of root formation, the patient's age, and intrusion severity should be taken into consideration. This study aimed to report a 10-year follow-up of two patients that suffered permanent incisor (PI) traumatic injury who had a similar root development (incomplete rooting) but different results. In the first case, the treatment of choice was follow-up. The patient showed gingival alteration and root resorption of tooth 21. Calcium hydroxide therapy and root canal filling were performed twice because of not attending callback. After finishing the endodontic treatment, follow-up visits showed no abnormalities. In the second case, the treatment of choice was watch and wait to the teeth 11 and 21. After 7 months spontaneous eruption of both teeth was detected. Radiographic examination showed atypical root formation and almost completely pulp canal obliteration, 8 years later. In the follow-up, visit after 10 years was observed complete crow and pulp canal obliteration. It was concluded that PI intrusion treatments are good intervention alternatives, as they proved to be successful after a 10-year follow-up period.

Regeneration (revitalization) of infected necrotic pulp tissue has been an important issue in endodontics for more than a decade. Based on a series of case reports, there appears to be evidence that new soft tissue can enter the root canal with a potential for subsequent hard tissue deposition resulting in a narrowing of the root canal. Very little is presently known about the exact nature of this tissue growing into the canal and how it may behave in the long term. In the case of regeneration of necrotic non-infected pulp tissue, a series of clinical and histological studies have shown that such events may take place in four variants: (i) Revascularization of the pulp with accelerated dentin formation leading to pulp canal obliteration. This event has a good long-term prognosis. (ii) Ingrowth of cementum and periodontal ligament (PDL). The long-term prognosis for this event is not known. (iii) Ingrowth of cementum, PDL, and bone. The long-term prognosis is only partly known, but cases developing an internal ankylosis have been described. (iv) Ingrowth of bone and bone marrow is a rare phenomenon and the long-term prognosis does not appear to be good. Based on current knowledge, expectations with respect to pulp regeneration (revitalization) of infected necrotic dental pulps are difficult to predict; more information than now available is needed before procedures for pulpal regeneration can be routinely recommended with a predictable long-term prognosis.

Pulp canal obliteration (PCO) is a sequela of tooth trauma. The dental clinician faced with this condition has to make a difficult decision. The aim of this study was to evaluate the clinical signs and symptoms associated with teeth with PCO and to assess the status of the periapical tissues using the periapical index (PAI) as an aid in making a treatment decision. The study included teeth diagnosed with PCO in patients with a history of traumatic injury to the involved teeth. Histories of associated signs and symptoms including pain, swelling and drainage from a sinus tract were elicited. Tooth color, sensibility to electric pulp testing, mobility and percussion tenderness were recorded. The periapical status was assessed using the PAI. Two hundred and seventy-six teeth were diagnosed with PCO. One hundred and fifty-seven (56.9%) and 119 (43.1%) demonstrated partial or total PCO, respectively. Yellow discoloration presented most frequently, occurring in 186 (67.4%) teeth. Sixty-two (33.3%) of these had developed periapical lesions and reacted negatively to sensibility testing. Fifty-seven (30.7%) of these teeth presented radiographically with a normal periapical appearance and reacted normally to sensibility testing, whereas 67 (36.0%) presented with small changes in the periapical bone pattern and reacted in the high normal range to sensibility testing. Teeth with PAI scoresor =2 presented with occasional spontaneous pain. Teeth with PAI scoresor =3 presented with clinical symptoms and signs ranging from pain on percussion to spontaneous pain, and slight swelling to sinus tract drainage. Based on the findings of this study, endodontic treatment should be initiated in teeth with tenderness to percussion, PAI scoresor =3 and a negative response to sensibility testing.

Thirty-four patients with 45 avulsed and replanted permanent teeth were followed for 1 year. All teeth were soaked in tetracycline before replantation. In addition, enamel matrix derivative was used in teeth with dry storage times exceeding 30 min. Splinting was carried out with a non-rigid titanium splint and was limited to 7-10 days. Within that period, root canal treatment was begun in all teeth with a closed apex, whereas teeth with an open apex and ideal post-traumatic storage were not instrumented. All patients were given tetracycline systematically for 10 days. The survival rate of replanted avulsed permanent teeth was 95.6% at the 1-year follow-up. In 82.2%, root canal treatment was performed. Pulp survival was never observed, but three teeth had pulp canal obliteration. Normal periodontal healing was observed in 57.7% of teeth; 42.3% of teeth showed external root resorption (28.9% replacement resorption, 6.7% infection-related resorption, 6.7% surface resorption). The occurrence of replacement resorption correlated with the period of extraoral dry storage. Compared with other clinical studies on avulsed and replanted teeth, the present study reports a higher percentage of periodontal healing. The favorable treatment outcome may be associated with a strict protocol to enforce endodontic treatment, the use of topical and systemic tetracycline, and the relatively high number of ideally stored teeth following avulsion. In contrast, the present study has a follow-up period limited to 1 year.

A longitudinal outcome study was designed to identify variables that influenced tooth survival as well as pulpal and periodontal outcomes of laterally luxated permanent maxillary incisors of children and adolescents. All cases were treated between June 1988 and June 1998 in a teaching hospital clinic. Clinical and radiographic data were collected for 42 patients (26 males, 16 females) that represented 58 permanent maxillary incisors. Mean age at the time of injury was 11.4 years (range: 6.3-17.8 years). Mean follow-up time was 1460 days (range: 183-3905 days). In the entire sample (n = 58), no incisors required extraction. Survival analysis and logistic regression were used to identify variables significantly related to the survival and healing outcomes of these incisors. Pulp necrosis (PN) (40%) and pulp canal obliteration (PCO) (40%) were common healing complications. Proportional hazards (Cox) regression showed that PN develops within the first year. Logistic regression demonstrated that root development (P = 0.3, PN; P = 0.8, PCO) and extent of lateral luxation (P = 0.5, PN; P = 0.9, PCO) were not significantly related to PN and PCO. This study provides the first report of incisor survival in children and adolescents following lateral luxation injuries.

A longitudinal outcome study was undertaken to identify variables that significantly influenced outcomes for extruded permanent maxillary incisors of children and adolescents. Clinical and radiographic data was available for 35 patients (18 males, 17 females) representing 55 incisors. Mean age at the time of injury was 10.6 years (range: 7.1-17.8 years). Mean time elapsed to follow up was 1320 days (range: 423-2887 days). Survival analysis was used to identify variables significantly related to the prognosis of these teeth. The loss of an incisor following extrusion was uncommon as only one tooth (1/55) required extraction. There was no statistically significant difference in survival between severely extruded teeth and avulsions that had been stored in physiological media (P > 0.10). Pulp necrosis (PN) was the most common complication following injury (43%) and it most often occurred during the first year. Although not statistically significant, a trend towards increased PN was found with more severely extruded teeth (P = 0.20, relative risk = 2.08). Pulp canal obliteration (PCO) was the second most common outcome (35%). The degree of extrusion was proven to be significantly associated with the development of PCO (P = 0.03, relative risk = 0.33). Root resorption was an uncommon outcome (3/55). This study represents the first outcome data on extrusions to permanent maxillary incisors in an exclusively pediatric population.

Two hundred and eighty-seven children with a total of 545 traumatized primary upper incisors were followed using standardized procedures until the age of 10. Extraction was the only treatment offered when intervention was necessary. The immediate as well as the long-term consequences of trauma were studied on the basis of this material. Consequences in the primary dentition comprised: color changes (53%), pulp necrosis (25%), pulp canal obliteration (36%), gingival retraction (6%), permanent displacement after luxation (5-22%), pathological root resorption (1-10%) as well as disturbances in physiological root resorption (4%) and, lastly, premature tooth loss (46%). In a multivariate analysis of the development of pulp necross in primary teeth after trauma, the following decisive factors were found: age of the patient at the time of injury, degree of displacement of the tooth as well as the degree of loosening and presence of crown fracture. The factors found to influence development of pulp canal obliteration were: displacement of the tooth at time of injury as well as detectable physiologic root resorption at time of trauma. The presence of crown fracture seemed to decrease the risk of obliteration. The need for scientifically based treatment strategies for managing and reducting complications after trauma in the primary dentition is stressed.

Pulpal healing patterns were studied in a clinical material of 637 luxated and 95 root-fractured permanent incisors followed routinely for up to 11 years. It was found that pulpal healing patterns could generally be divided into 3 groups according to the degree of injury sustained by the pulp: little, moderate or severe. Thus after luxation injuries, pulp survival could be without radiographic change (PS), with pulp canal obliteration (PCO) or nonhealing (pulp necrosis (PN)). After root fracture, similar healing patterns could be observed: healing by hard tissue union of fragments (HT), by connective tissue union of fragments (CT) or by nonunion due to interposition of granulation tissue between fragments (GT) resulting from PN of the coronal fragment. In both trauma situations, healing or nonhealing could be determined by type of luxation injury, stage of root development and type of fixation used (forceful application of orthodontic bands vs. passively applied acid-etch fixation). Pulpal healing complications (PN or GT) were based on clinical findings (coronal discoloration, loss of pulpal sensibility) and radiographic findings (resorption processes of the lamina dura at the root apex or at the level of the root fracture). However, in both injury groups the same changes could also be seen to be intermediate steps in the pulpal healing process. Based on findings from these studies, hypotheses for the mechanics of pulpal healing are proposed as well as guidelines for acute and later treatment of dental luxations, root fractures and the diagnosis of healing complications.

The records of 85 patients treated for 95 root fractures of permanent incisors and followed regularly for up to 11 years were studied with respect to healing events after injury. The radiographic exposure best suited for disclosing root fractures in the apical third of the root was a steep occlusal exposure, while a conventional bisecting angle periapical exposure was optimal for revealing fractures in the cervical third. It is concluded that both exposures should, therefore, be used at the initial examination at the time of injury. Root resorption processes were observed in 60% of the material and could usually be detected within one year after injury. These preceded fracture healing and obliteration of the apical and/or coronal root canals. The changes observed represented one or more of four resorption entities: 1) external surface resorption, characterized by the rounding of the fracture edges mesially and/or distally; 2) internal surface resorption, manifested as rounding of the fracture edges centrally, in the apical and coronal root canals, at the intersection between the pulp canal and fracture line; 3) internal tunneling resorption, going behind the predentin layer and burrowing along the root canal walls of the coronal fragment; and 4) transient apical breakdown of the apical lamina dura. While the resorption processes were self-limiting and required no treatment, the pattern of resorption and pulp canal obliteration appeared to be decisive for the type of fracture healing. Thus, all resorption entities collectively and internal tunneling resorption particularly were significantly related to healing at the fracture site by interposition of connective tissue. However, when seen alone, internal surface resorption was significantly related to fracture healing by hard tissue union. The different root resorption entities may represent osteoclastic activity connected with the ingrowth of new vascularized connective tissue into the fracture site or the coronal part of the root canal.

Traumatic dental injuries are very frequent in both the primary and permanent dentition. As these often imply combined injury to both the pulp and periodontium, a variety of healing complications may arise, such as pulp necrosis, pulp canal obliteration, root resorption and loss of marginal attachment. Furthermore, trauma in the primary dentition can be transmitted to the permanent successors, leading to a variety of developmental disturbances. The analysis of the etiology of these complications has hitherto been seriously hampered by a lack of agreement on the registration of the extent of injury to the tooth and its supporting structures (i.e. trauma classification), lack of agreement on the definition of healing complications and shortcomings in the statistical analysis of follow-up studies of traumatized primary and permanent teeth. The consequences of these shortcomings are described with respect to the evaluation of prognosis of various types of trauma. Suggestions are made for data collection and analysis of future trauma studies which should enable the identification of factors determining the outcome of traumatic dental injuries. Through a perusal of recent dental literature, various trauma entities and treatment procedures are evaluated. Furthermore, areas are outlined where present knowledge does not allow rational treatment selection or prognosis evaluation.

A population of 400 patients, comprising 637 luxated permanent teeth was studied prospectively with respect to the development of pulp necrosis after luxation injuries. The patients were treated for traumatic dental injuries over a period of 10 years. While initial treatment was provided according to established treatment guidelines by the attending oral surgeon at the emergency room, follow-up examination and treatment was provided by one oral surgeon. It appeared that pulp necrosis occurred soon after injury, within 3 months after concussion, within the 1st yr after subluxation and extrusion, and might be diagnosed up to 2 yr after lateral- and intrusive luxation. While many factors, when considered one at a time, were found to have a significant or nearly significant died on the development of pulp necrosis (i.e. type of injury, age of patient, stage of root development, degree of dislocation, reduction/repositioning procedure, type of fixation, restorations in place at the lime of injury), a multivariate regression analysis revealed that when the type of injury (diagnosis) and stage of root development were taken into account, the effect of other factors was no longer significant. The risk of pulp necrosis increased with the extent of injury, i.e. concussion and subluxation represented the least risk, followed in ascending order by extrusive-, lateral-, and intrusive luxation. Moreover, teeth with completed root formal ion demonstrated a greater risk of pulp necrosis than teeth with incomplete root formation. No treatment effect could be demonstrated. However, as treatment was performed according to established guidelines, which might introduce bias, it would appear justified to conduct randomized clinical studies in order to determine the value of different forms of treatment (e.g. reduction and fixation of luxated teeth) to improve the prognosis with respect to the development of pulp necrosis after injury. In conclusion, the major factors influencing development of pulp necrosis after luxation injuries appear to be the extent of the initial injury to the pulp and periodontium, as reflected by the type of luxation, and the repair potential of the injured tooth, as reflected by the stage of root development.

The 172 periodontally injured teeth of 76 patients were examined clinically and radiographically 6–32 months (mean 22 months) following injury. Multiple linear regression analysis, in which all the variables examined were forced into the model, was used to study the effect of three variables (stage of root formation, type of luxation, and duration of immobilization) in conjunction with one or two variables having the highest explanatory effect on 4 radiographically diagnosed late complications: external replacement resorption, pulp obliteration, loss of marginal alveolar bone and periapical inflammatory changes. External root resorption was found in 19% of cases and was only statistically related to the type of first aid treatment (p< 0.001), although the duration of immobilization was a more decisive factor for ankylosis than the other two variables. Partial or total obliteration of the pulp was recorded in 24% of the teeth examined and was statistically related to the age of the patient (p< 0.001) and the stage of root formation (p

A material of 637 concussed, subluxated, extruded, laterally luxated and intruded permanent incisors was analyzed with respect to factors influencing the development of pulp canal obliteration (PCO) after injury. A total of 96 (15%) developed partial PCO; 9 of these (1% of the total material) went on to develop total PCO. Only 2 teeth exhibited yellow discoloration of the clinical crown and 1 showed grey discoloration. Sensibility to electrometric pulp testing of the teeth with PCO was not significantly different from sensibility of contralateral homologues at the final examination (except for after lateral luxation, where the teeth with PCO had a significantly lower perception threshold). PCO was significantly more frequent among teeth with incomplete root formation than in teeth where root formation was completed. Extrusion, lateral luxation and intrusion showed more frequent occurrence of PCO than did concussion and subluxation. Moreover, the use of orthodontic band/resin splints significantly increased the occurrence of PCO, presumably due to the additional trauma of forceful placement and cementation of orthodontic bands in contrast to the relatively passive placement of an acid-etch/resin splint. Based on previous and present clinical and radiographic findings concerning pulp response to luxation injuries, it is suggested that PCO is a sequel to revascularization and/or reinnervation of a damaged pulp after injury.