- Email: [email protected]
Prognosis and complications of mature teeth after lateral luxation
Original Contributions
Systematic Review Prognosis and complications of mature teeth after lateral luxation A systematic review Danielle Clark, DipDH, BSc, MSc; Liran Levin, DMD ABSTRACT Background. Dental trauma injuries are frequent in children and adolescents and can result in a sequela of future complications. Lateral luxation injuries are diagnosed when a tooth becomes displaced in a position other than axial and is often associated with alveolar bone fracture. Although the tooth is not immediately lost, pulp canal obliteration or pulpal necrosis can occur. The objective of this systematic review was to gather existing data on lateral luxation injuries to mature teeth to evaluate their overall prognosis and reported complications. Types of Studies Reviewed. The authors conducted a systematic search of the literature using MEDLINE, PubMed, Embase, and Cochrane databases in February 2019. They hand searched reference lists to identify additional literature. The authors included prospective and retrospective observational studies in the search. They screened a total of 291 articles, downloaded 28 articles, and included 4 articles in the study. Results. The most frequent complication reported for mature teeth with lateral luxation was pulpal necrosis (44.2%). Less frequent findings included surface resorption (14.0%), inflammatory resorption (8.5%), pulp canal obliteration (8.1%), and replacement resorption (0.9%). The included studies were cohort studies, which resulted in great heterogeneity, and the authors could not attempt a meta-analysis. Conclusions and Practical Implications. A large number of permanent teeth that experience lateral luxation are at risk of developing pulpal necrosis and other complications. Careful followup is required for these patients to treat complications as early as possible. Furthermore, the authors of this systematic review emphasize the importance of consistent reporting of dental trauma outcomes. Key Words. Tooth injury; tooth loss; complications; resorption; ankyloses. JADA 2019:150(8):649-655 https://doi.org/10.1016/j.adaj.2019.03.001
D
ental trauma is a term used for injury (trauma) to the teeth and periodontium, including proximate tissues, lips, tongue, and jawbones. Although dental trauma injuries often occur in a younger population, they remain prevalent in older patients as well. The treatment of certain traumatic dental injuries varies depending on whether the injury was sustained by a permanent tooth or a primary tooth.1 One of the most frequently experienced traumatic dental injuries are lateral luxation injuries. These injuries make up 29.5% through 57.0% of all traumatic dental injuries.2-5 Lateral luxation injuries occur when a tooth is displaced in the socket in either the palatal and lingual or labial direction and are often associated with alveolar bone ridge fracture.1,6 This displacement causes the tooth to be immobile, and percussion testing results in an ankylotic sound.1,6 Sensibility tests of lateral luxation injuries are often negative, and widening of the periodontal ligament space can be seen from eccentric or occlusal radiographs.1,6 Lateral luxation injuries are often treated by means of manual reduction and splinting. Occasionally, the tooth may be treated with a root canal procedure if indicated. These treatment recommendations are part of the guidelines put forward by the International Association of Dental Traumatology.1 JADA 150(8)
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Table 1. Search conducted in MEDLINE. SEARCH NO.
SEARCHES
RESULTS
1
(Tooth OR Teeth OR Dental).mp. [mp¼title, abstract, original title, name of substance word, subject heading word, protocol supplementary substance word, rare disease supplementary concept word, unique identifier, synonyms]
525,693
2
(Luxation OR Displace* or Injur* OR Dislodge*).m_titl.
304,639
3
(Outcome OR Follow up OR Survival OR Complication* OR Success OR Prognosis OR Consequence OR Evaluation).m_titl.
991,063
4
1 AND 2 AND 3
202
Damage to the pulp and periodontium caused by lateral luxation injury can heal over time. However, mature teeth that undergo this type of trauma may experience more complications in the future.7 This may be attributed to the fully developed root of mature teeth and the closure of the apical foramen. Lateral luxation injuries are at risk of developing complications such as pulpal necrosis and pulp canal obliteration. These complications can leave patients facing burdensome extractions, pulp-related treatments, and restorative procedures. Furthermore, these complications can arise years after treatment, emphasizing the importance of long-term follow-up of patients. Although root canal treatment might prolong the survival of a tooth, root canal teeth are at a higher risk of experiencing failure. In a 20-year follow-up study of teeth treated via root canal, researchers reported a 79% survival rate.8 Preventing dental trauma is important as it will limit the long-term consequences patients must handle. Despite available treatment recommendations, it is difficult to investigate the different treatments of dental injuries such as lateral luxation. Systematic reviews and meta-analyses are considered the best available evidence. However, dental trauma does not allow for randomized controlled trials owing to ethical considerations. Therefore, the best available evidence stems from cohort studies. Fortunately, systematic reviews of cohort studies is possible if the studies are not overly heterogeneous. Thus, our purpose in this systematic review was to analyze the participants, intervention, comparison, outcomes, and study design (PICOS) question “What is the prognosis of mature teeth after lateral luxation injuries in the general population?” METHODS Protocol We conducted this systematic review according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.9 We used the PICOS guidelines to develop the guiding question and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and flowchart to facilitate the process.10 Because the review included nonrandomized controlled studies, we used the Newcastle-Ottawa Scale to assess risk of bias.11 Eligibility criteria Types of Studies Ethical considerations limit the availability of randomized controlled trials. Therefore, the inclusion criteria were as follows: prospective or retrospective observational studies, English language only, and studies assessing prognosis of lateral luxation injuries in mature teeth. We placed no restrictions on how a mature tooth was defined. We excluded case series, case reports, and reviews. Exclusion criteria encompassed studies that assessed the effect of lateral luxation injuries sustained in primary teeth on their permanent successors as well as studies that assessed teeth with multiple injuries.
ABBREVIATION KEY NA: Not applicable. PICOS: Participants, intervention, comparison, outcomes, and study design.
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Types of Participants Studies were restricted to human participants, with no restrictions on age, sex, and sample size. Although the objective of the study was to assess mature teeth, we placed no age restriction during the search to ensure the inclusion of all appropriate studies. Types of Interventions Two possible types of interventions exist for lateral luxation injuries. One involves repositioning and splinting the tooth, and the second includes the former with a root canal treatment. JADA 150(8)
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Identification
Records identified through database searching (n = 628) • MEDLINE (n = 202) • PubMed (n = 233)
• Embase (n = 187) • Cochrane (n = 6)
Additional records identified through other sources (n = 9)
Eligibility
Screening
Records after duplicates removed (n = 291)
Records screened (n = 291)
Records excluded (n = 263)
Full-text articles assessed for eligibility (n = 28)
Full-text articles excluded, with reasons (n = 24)
Included
Studies included in qualitative synthesis (n = 4)
• No follow-up/follow-up not specific for laterally luxated teeth n = 7 • Luxation injury type not specified/Injury not lateral luxation n = 7 • Lateral luxation injury combined with other injury n = 2 • No differentiation between immature and mature root development n = 3 • Same patient cohort in studies n = 1 • Data specific for immature/primary only n = 4
Studies included in quantitative synthesis (meta-analysis) (n = 0)
Figure. Flowchart of study selection.
Types of Outcome Measures We considered all reported outcomes. We statistically assessed only outcomes reported by 2 or more studies. These outcomes included pulp canal obliteration, pulp necrosis, surface resorption, inflammatory resorption, replacement resorption, and internal resorption. Search strategy We conducted an electronic search in the following databases: MEDLINE, PubMed, Embase, and Cochrane Library in February 2019. We included additional studies via hand searching through reference lists as well as through correspondence (experts, dental organizations). We conducted the search in MEDLINE as shown in Table 1. We modified this search for the other databases accordingly using the PICOS question “What is the prognosis of mature teeth after lateral luxation injuries in the general population?” Data collection and analysis We excluded downloaded articles if they met any of the following criteria: lateral luxation evaluation was not specified, the same cohort of patients was used for another study, there was no followup period, multiple injuries were sustained to the tooth, or the study only contained data specific for immature teeth. The final criterion for inclusion was follow-up of mature teeth after sustaining a lateral luxation injury. Data extracted from the articles included authors, publication year, study design, sample size, treatment, follow-up period, and assessed outcomes. We assessed risk of bias using the Newcastle-Ottawa Scale.11 Owing to the heterogeneity of the articles, we did not attempt a meta-analysis. To summarize the main findings of the articles, we included the most common complications. We included complications that were reported in 2 or more studies in the analysis. We added together the number of teeth that experienced a specific complication and then divided that figure by the total number of laterally luxated teeth to determine a percentage for the specific complication. JADA 150(8)
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Table 2. Characteristics of included studies.
STUDY Andreasen and Colleagues,15 1985
STUDY DESIGN
SAMPLE SIZE (LATERAL LUXATED MATURE TEETH) FOLLOW-UP TREATMENT
LOCATION
Retrospective Department of Oral and Maxillofacial cohort Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
Ferrazzini Pozzi Prospective and Colleagues,14 cohort 2008
NA*
88
Minimum 5 y, Splinting or no up to 10 y treatment
44
Minimum 4 y
Manual reduction and splinting Manual reduction and splinting
Hecova and Colleagues,13 2010
Retrospective Faculty Hospital, Pilsen, Czech cohort Republic
141
Minimum 5 y
Hermann and Colleagues,12 2012
Retrospective Department of Oral and Maxillofacial cohort Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
131
Range: 10.8 Manual mo - 22 y reduction and Median: 1.3 y splinting
* NA: Not applicable.
RESULTS There was a total of 637 articles in the search results, and after we removed duplicates, 291 remained. We screened the titles and abstracts and excluded irrelevant studies. We downloaded 28 articles and assessed them for eligibility (Figure). After screening, we included 4 articles.12-15 The included studies were both retrospective and prospective in nature. We excluded 3 studies because the measured outcomes were not differentiated between mature and immature teeth.16-18 Additional characteristics of the included studies are presented in Table 2. Manual reduction in combination with splinting procedures appeared to be the most common course of treatment for lateral luxation injuries in mature teeth (Table 2). We assessed the quality of the studies using the Newcastle-Ottawa Scale (Table 3). Each of the 4 included studies represented the exposed cohort, did not have the outcome of interest at the beginning of the study, and had an adequate follow-up of the study cohort (Table 3). Because the included studies were not randomized controlled trials, the outcomes varied across the studies, and, as a result, we did not attempt a meta-analysis. The results we describe in Table 4 only include outcomes that 2 or more studies shared. After pooling the results, we found that pulp necrosis was the most frequent complication among mature teeth with lateral luxation injuries (44.2%). Surface resorption was the second most frequent complication (14.0%), whereas pulp canal obliteration and inflammatory resorption were less frequent (8.1% and 8.5%, respectively). The least common complication was replacement resorption (0.9%). DISCUSSION The results of this systematic review show the relatively high frequency of complications after lateral luxation injuries are sustained to mature teeth. Pulp necrosis seems to be the most frequent complication (44.2%) but is less common in immature teeth with lateral luxation injury (17.5%).19 The frequency of complications and the type of complications of teeth with lateral luxation varied between the 4 included studies. The included studies consistently reported that replacement resorption was a relatively rare complication of laterally luxated teeth. There was less consistency in the reports on the frequency of pulpal necrosis. Possible explanations for the differences include the different follow-up periods, reporting of different outcomes, and different assessments or tools used for diagnosis. This finding emphasizes the need to follow up frequently with patients to monitor teeth with lateral luxation.1 If pulpal necrosis is not identified and treated early, it can lead to other sequelae such as dental abscesses or resorption that might necessitate tooth extraction. The development of pulpal necrosis in traumatized teeth is influenced by root maturity and delay of treatment.15,20-22 Although less common, other outcomes such as pulp canal obliteration, inflammatory resorption, and surface resorption are possible and should be monitored for at follow-up visits. These findings are unique to mature teeth that have experienced lateral luxation. In a systematic review of the complications that occur from lateral luxation injuries in immature teeth, the authors found that 652
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Table 3. Quality assessment of included studies based on the Newcastle-Ottawa Scale.* STUDY
SELECTION
COMPARABILITY
Demonstration That the Outcome Representative Selection of Interest Was of the Not Present at of the Exposed Nonexposed Ascertainment the Start Cohort Cohort of Exposure of the Study
Comparability of Cohorts Based on Study Design or Analysis
OUTCOME
Adequate Follow-up Adequacy Assessment for of of Outcomes Follow-up Outcome to Occur of Cohorts
Andreasen and Colleagues,13 1985
Y*
NA†
Y
Y
NA
Y
Y
Y
Ferrazzini Pozzi and Colleagues,12 2008
Y
NA
Y
Y
NA
Y
Y
Y
Hecova and Colleagues,11 2010
Y
NA
Unclear
Y
NA
Unclear
Y
Y
Hermann and Colleagues,10 2012
Y
NA
Y
Y
NA
Y
Y
Y
* Y: Yes † NA: Not applicable.
Table 4. Pooled reports of complications of laterally luxated mature teeth.* PULP CANAL OBLITERATION
PULP NECROSIS
SURFACE RESORPTION
INFLAMMATORY RESORPTION
REPLACEMENT RESORPTION
NO COMPLICATIONS
NA†
68 of 88
NA
NA
NA
0 of 88
Ferrazzini Pozzi and Colleagues,12 2008
7 of 44
NA
NA
NA
1 of 44
19 of 44
Hecova and Colleagues,11 2010
8 of 141
89 of 141
1 of 141
21 of 141
1 of 141
40 of 141
NA
2 of 131
37 of 131
2 of 131
1 of 131
0 of 131
15 (185)
159 (360)
38 (272)
23 (272)
3 (316)
59 (404)
8.1
44.2
14.0
8.5
0.9
14.6
STUDY Andreasen and Colleagues,13 1985
Hermann and Colleagues,10 2012 Pooled Incidence No. (N) %
* The number of complications is not mathematically aligned with the number of teeth without complications because some teeth had multiple complications. Furthermore, only complications that were reported in 2 or more studies are included in this table. For example, if only 1 study included marginal periodontal breakdown as a complication, it is not included in this table. † NA: Not applicable.
the most prevalent outcome was pulp canal obliteration (31.3%).19 On the contrary, pulp canal obliteration is a much less common finding in mature teeth (8.1%). Although there are several possible adverse outcomes of lateral luxation injuries, ranging from pulpal necrosis to inflammatory resorption, clinicians should be aware of which complications are most frequent in either mature or immature teeth. The timeline of when to expect these complications also has been studied previously; however, the times at which the complications occur do vary, and thus it is important for clinicians to have frequent follow-ups with patients to detect complications as soon as possible.13 This information will help aid clinicians in making the proper diagnosis at follow-up appointments and performing appropriate treatment interventions such as elective endodontic treatment to prevent future complications. Elective endodontic treatment is an option for dental trauma cases. For lateral luxation injuries specifically, current guidelines suggest monitoring the pulpal condition of the tooth and only performing endodontic treatment if the pulp becomes necrotic.1 However, the decision to perform elective endodontic treatment is based on the patient’s specific situation. The partial evidence in the treatment of dental trauma is a limitation to the current guidelines. Because randomized controlled trials are not ethical in studies of dental trauma, the best available evidence is from cohort studies. Therefore, it becomes critical that the reported JADA 150(8)
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outcomes are homogeneous among studies. Suggestions for these outcomes were published in 2018.23 Using these guidelines will allow for better evidenced-based decisions in the long-term future. In addition to focusing on secondary preventative measures for dental trauma, it is important to consider primary prevention as a priority. After a traumatic dental injury such as lateral luxation has occurred, the patient is at risk of developing a lifetime of possible complications. Therefore, prevention of traumatic dental injuries is key. A call for prevention based on the International Association of Dental Traumatology guidelines was provided by Levin and Zadik.24 This included providing public lectures about the prevention and management of dental trauma, educating all dental staff about emergency management of dental trauma, recognizing patients who are at high risk of experiencing dental trauma, and providing medium solution kits for avulsed teeth in first aid kits at public facilities.24 Despite education efforts, however, compliance is not achieved necessarily, particularly with mouthguard use.25 For example, military populations are at a high risk of experiencing dental trauma.26,27 Although educational efforts have been applied, more official reinforcement may be required to mandate mouthguard use.25 This may apply to all high-risk categories such as contact sports.28,29 The results of this systematic review show that 1 of the most prevalent traumatic dental injuries presents complications. Therefore, serious effort should be made by dental health care professionals to prevent traumatic dental injuries at both the private practice patientclinician level, as well as on a broader public health level. Limitations of this systematic review involve the inclusion of retrospective and prospective cohort studies. The inclusion of such studies presents confounding variables and bias, but the inclusion of randomized controlled trials was not possible. Furthermore, there is the possibility of detection bias because the reported outcomes were not necessarily measured homogeneously across the studies. It should be recognized that the pooled incidence reported in this study is based on heterogeneous studies and that not all reported complications of lateral luxation injuries are reported in Table 4. CONCLUSION This systematic review highlights the relatively high frequency of complications such as pulpal necrosis in permanent teeth with lateral luxation. This reinforces the importance of strict follow-ups of patients with lateral luxation injuries. Furthermore, this systematic review emphasizes the importance of consistent reporting of dental trauma outcomes. Because randomized controlled trials are nearly impossible in the dental trauma field, it is crucial to have well-conducted cohort studies to guide evidenced-based decision making. n
Ms. Clark is a clinical instructor, Division of Periodontology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. Dr. Levin is a professor, Division of Periodontology, Faculty of Medicine and Dentistry, University of Alberta, 5-468 Edmonton Clinic Health
1. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries, 1: fractures and luxations of permanent teeth. Dent Traumatol. 2012;28(1):2-12. 2. Ritwik P, Massey C, Hagan J. Epidemiology and outcomes of dental trauma cases from an urban pediatric emergency department. Dent Traumatol. 2015;31(2):97-102. 3. Arikan V, Sari S, Sonmez H. The prevalence and treatment outcomes of primary tooth injuries. Eur J Dent. 2010;4(4):447-453. 4. Jesus MA, Antunes LA, Risso Pde A, Freire MV, Maia LC. Epidemiologic survey of traumatic dental injuries in children seen at the Federal University of Rio de Janeiro, Brazil. Braz Oral Res. 2010;24(1):89-94. 5. Soporowski NJ, Allred EN, Needleman HL. Luxation injuries of primary anterior teeth-prognosis and related correlates. Pediatri Dent. 1994;16(2):96-101.
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Academy, 11405 - 87 Avenue NW, 5th Floor, Edmonton, AB, Canada T6G 1C9, e-mail [email protected]. Address correspondence to Dr. Levin. Disclosure. Ms. Clark and Dr. Levin did not report any disclosures.
6. Andreasen FM, Andreasen JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations. Endod Dent Traumatol. 1985; 1(5):160-169. 7. Honório HM, de Alencar CRB, Pereira Júnior ES, de Oliveira DSB, de Oliveira GC, Rios D. Posttraumatic displacement management: lateral luxation and alveolar bone fracture in young permanent teeth with 5 years of follow-up. Case Rep Dent. 2015; 634237. 8. Prati C, Pirani C, Zamparini F, Gatto MR, Gandolfi MG. A 20-year historical prospective cohort study of root canal treatments: a multilevel analysis. Int Endod J. 2018;51(9):955-968. 9. Reeves B, Deeks J, Higgins J, Wells G. Including non-randomized studies. In: Cochrane Handbook for Systematic Reviews of Interventions. Chichester, UK: John Wiley & Sons; 2008.
10. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. 11. Wells G, Shea B, O’Connell D, et al. The NewcastleOttawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2009. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford. asp. Accessed December 11, 2016. 12. Hermann NV, Lauridsen E, Ahrensburg SS, Gerds TA, Andreasen JO. Periodontal healing complications following extrusive and lateral luxation in the permanent dentition: a longitudinal cohort study. Dent Traumatol. 2012;28(5):394-402. 13. Hecova H, Tzigkounakis V, Merglova V, Netolicky J. A retrospective study of 889 injured permanent teeth. Dent Traumatol. 2010;26(6):466-475.
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14. Ferrazzini Pozzi EC, von Arx T. Pulp and periodontal healing of laterally luxated permanent teeth: results after 4 years. Dent Traumatol. 2008;24(6):658662. 15. Andreasen FM, Pedersen BV. Prognosis of luxated permanent teeth: the development of pulp necrosis. Endod Dent Traumatol. 1985;1(6):207-220. 16. Oikarinen K, Gundlach KK, Pfeifer G. Late complications of luxation injuries to teeth. Endod Dent Traumatol. 1987;3(6):296-303. 17. Nikoui M, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population, III: lateral luxations. Dent Traumatol. 2003;19(5):280285. 18. Rocha Lima TF, Nagata JY, de Souza-Filho FJ, de Jesus Soares A. Post-traumatic complications of severe luxations and replanted teeth. J Contemp Dent Pract. 2015; 16(1):13-19.
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19. Clark D, Levin L. Prognosis and complications of immature teeth following lateral luxation: a systematic review. Dent Traumatol. 2018;34(4):215-220. 20. Rook WP, Gordon PH, Friend LA, Grundy MC. The relationship between trauma and pulp death in incisor teeth. Br Dent J. 1974;136(6):236-239. 21. Eklund G, Stalhane, Hedegard B. Traumatized permanent teeth in children aged 7-15 years, part III: a multivariate analysis of post-traumatic complications of subluxated and luxated teeth. Swed Dent J. 1976;69(6): 179-189. 22. Magnusson B, Holm AK. Traumatised permanent teeth in children-a follow-up, I: pulpal complications and root resorption. Sven Tandlak Tidskr. 1969;62(2):61-70. 23. Kenny KP, Day PF, Sharif MO, et al. What are the important outcomes in traumatic dental injuries? An international approach to the development of a core outcome set. Dent Traumatol. 2018;34(1):4-11.
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24. Levin L, Zadik Y. Education on and prevention of dental trauma: it’s time to act! Dent Traumatol. 2012;28(1):49-54. 25. Zadik Y, Jeffet U, Levin L. Prevention of dental trauma in a high-risk military population: the discrepancy between knowledge and willingness to comply. Mil Med. 2010;175(12):1000-1003. 26. Zadik Y, Levin L. Oral and facial trauma among paratroopers in the Israel Defense Forces. Dent Traumatol. 2009;25(1):100-102. 27. Zadik Y, Levin L. Orofacial injuries and mouth guard use in elite commando fighters. Mil Med. 2008;173(12): 1185-1187. 28. Levin L, Friedlander LD, Geiger SB. Dental and oral trauma and mouthguard use during sport activities in Israel. Dent Traumatol. 2003;19(5):237-242. 29. Rattai J, Levin L. Oral injuries related to ice hockey in the province of Alberta, Canada: trends over the last 15 years. Dent Traumatol. 2018;34(2):107-113.
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Systematic Review Prognosis and complications of mature teeth after lateral luxation A systematic review Danielle Clark, DipDH, BSc, MSc; Liran Levin, DMD ABSTRACT Background. Dental trauma injuries are frequent in children and adolescents and can result in a sequela of future complications. Lateral luxation injuries are diagnosed when a tooth becomes displaced in a position other than axial and is often associated with alveolar bone fracture. Although the tooth is not immediately lost, pulp canal obliteration or pulpal necrosis can occur. The objective of this systematic review was to gather existing data on lateral luxation injuries to mature teeth to evaluate their overall prognosis and reported complications. Types of Studies Reviewed. The authors conducted a systematic search of the literature using MEDLINE, PubMed, Embase, and Cochrane databases in February 2019. They hand searched reference lists to identify additional literature. The authors included prospective and retrospective observational studies in the search. They screened a total of 291 articles, downloaded 28 articles, and included 4 articles in the study. Results. The most frequent complication reported for mature teeth with lateral luxation was pulpal necrosis (44.2%). Less frequent findings included surface resorption (14.0%), inflammatory resorption (8.5%), pulp canal obliteration (8.1%), and replacement resorption (0.9%). The included studies were cohort studies, which resulted in great heterogeneity, and the authors could not attempt a meta-analysis. Conclusions and Practical Implications. A large number of permanent teeth that experience lateral luxation are at risk of developing pulpal necrosis and other complications. Careful followup is required for these patients to treat complications as early as possible. Furthermore, the authors of this systematic review emphasize the importance of consistent reporting of dental trauma outcomes. Key Words. Tooth injury; tooth loss; complications; resorption; ankyloses. JADA 2019:150(8):649-655 https://doi.org/10.1016/j.adaj.2019.03.001
D
ental trauma is a term used for injury (trauma) to the teeth and periodontium, including proximate tissues, lips, tongue, and jawbones. Although dental trauma injuries often occur in a younger population, they remain prevalent in older patients as well. The treatment of certain traumatic dental injuries varies depending on whether the injury was sustained by a permanent tooth or a primary tooth.1 One of the most frequently experienced traumatic dental injuries are lateral luxation injuries. These injuries make up 29.5% through 57.0% of all traumatic dental injuries.2-5 Lateral luxation injuries occur when a tooth is displaced in the socket in either the palatal and lingual or labial direction and are often associated with alveolar bone ridge fracture.1,6 This displacement causes the tooth to be immobile, and percussion testing results in an ankylotic sound.1,6 Sensibility tests of lateral luxation injuries are often negative, and widening of the periodontal ligament space can be seen from eccentric or occlusal radiographs.1,6 Lateral luxation injuries are often treated by means of manual reduction and splinting. Occasionally, the tooth may be treated with a root canal procedure if indicated. These treatment recommendations are part of the guidelines put forward by the International Association of Dental Traumatology.1 JADA 150(8)
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Copyright ª 2019 American Dental Association. All rights reserved.
649
Table 1. Search conducted in MEDLINE. SEARCH NO.
SEARCHES
RESULTS
1
(Tooth OR Teeth OR Dental).mp. [mp¼title, abstract, original title, name of substance word, subject heading word, protocol supplementary substance word, rare disease supplementary concept word, unique identifier, synonyms]
525,693
2
(Luxation OR Displace* or Injur* OR Dislodge*).m_titl.
304,639
3
(Outcome OR Follow up OR Survival OR Complication* OR Success OR Prognosis OR Consequence OR Evaluation).m_titl.
991,063
4
1 AND 2 AND 3
202
Damage to the pulp and periodontium caused by lateral luxation injury can heal over time. However, mature teeth that undergo this type of trauma may experience more complications in the future.7 This may be attributed to the fully developed root of mature teeth and the closure of the apical foramen. Lateral luxation injuries are at risk of developing complications such as pulpal necrosis and pulp canal obliteration. These complications can leave patients facing burdensome extractions, pulp-related treatments, and restorative procedures. Furthermore, these complications can arise years after treatment, emphasizing the importance of long-term follow-up of patients. Although root canal treatment might prolong the survival of a tooth, root canal teeth are at a higher risk of experiencing failure. In a 20-year follow-up study of teeth treated via root canal, researchers reported a 79% survival rate.8 Preventing dental trauma is important as it will limit the long-term consequences patients must handle. Despite available treatment recommendations, it is difficult to investigate the different treatments of dental injuries such as lateral luxation. Systematic reviews and meta-analyses are considered the best available evidence. However, dental trauma does not allow for randomized controlled trials owing to ethical considerations. Therefore, the best available evidence stems from cohort studies. Fortunately, systematic reviews of cohort studies is possible if the studies are not overly heterogeneous. Thus, our purpose in this systematic review was to analyze the participants, intervention, comparison, outcomes, and study design (PICOS) question “What is the prognosis of mature teeth after lateral luxation injuries in the general population?” METHODS Protocol We conducted this systematic review according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.9 We used the PICOS guidelines to develop the guiding question and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and flowchart to facilitate the process.10 Because the review included nonrandomized controlled studies, we used the Newcastle-Ottawa Scale to assess risk of bias.11 Eligibility criteria Types of Studies Ethical considerations limit the availability of randomized controlled trials. Therefore, the inclusion criteria were as follows: prospective or retrospective observational studies, English language only, and studies assessing prognosis of lateral luxation injuries in mature teeth. We placed no restrictions on how a mature tooth was defined. We excluded case series, case reports, and reviews. Exclusion criteria encompassed studies that assessed the effect of lateral luxation injuries sustained in primary teeth on their permanent successors as well as studies that assessed teeth with multiple injuries.
ABBREVIATION KEY NA: Not applicable. PICOS: Participants, intervention, comparison, outcomes, and study design.
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Types of Participants Studies were restricted to human participants, with no restrictions on age, sex, and sample size. Although the objective of the study was to assess mature teeth, we placed no age restriction during the search to ensure the inclusion of all appropriate studies. Types of Interventions Two possible types of interventions exist for lateral luxation injuries. One involves repositioning and splinting the tooth, and the second includes the former with a root canal treatment. JADA 150(8)
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August 2019
Identification
Records identified through database searching (n = 628) • MEDLINE (n = 202) • PubMed (n = 233)
• Embase (n = 187) • Cochrane (n = 6)
Additional records identified through other sources (n = 9)
Eligibility
Screening
Records after duplicates removed (n = 291)
Records screened (n = 291)
Records excluded (n = 263)
Full-text articles assessed for eligibility (n = 28)
Full-text articles excluded, with reasons (n = 24)
Included
Studies included in qualitative synthesis (n = 4)
• No follow-up/follow-up not specific for laterally luxated teeth n = 7 • Luxation injury type not specified/Injury not lateral luxation n = 7 • Lateral luxation injury combined with other injury n = 2 • No differentiation between immature and mature root development n = 3 • Same patient cohort in studies n = 1 • Data specific for immature/primary only n = 4
Studies included in quantitative synthesis (meta-analysis) (n = 0)
Figure. Flowchart of study selection.
Types of Outcome Measures We considered all reported outcomes. We statistically assessed only outcomes reported by 2 or more studies. These outcomes included pulp canal obliteration, pulp necrosis, surface resorption, inflammatory resorption, replacement resorption, and internal resorption. Search strategy We conducted an electronic search in the following databases: MEDLINE, PubMed, Embase, and Cochrane Library in February 2019. We included additional studies via hand searching through reference lists as well as through correspondence (experts, dental organizations). We conducted the search in MEDLINE as shown in Table 1. We modified this search for the other databases accordingly using the PICOS question “What is the prognosis of mature teeth after lateral luxation injuries in the general population?” Data collection and analysis We excluded downloaded articles if they met any of the following criteria: lateral luxation evaluation was not specified, the same cohort of patients was used for another study, there was no followup period, multiple injuries were sustained to the tooth, or the study only contained data specific for immature teeth. The final criterion for inclusion was follow-up of mature teeth after sustaining a lateral luxation injury. Data extracted from the articles included authors, publication year, study design, sample size, treatment, follow-up period, and assessed outcomes. We assessed risk of bias using the Newcastle-Ottawa Scale.11 Owing to the heterogeneity of the articles, we did not attempt a meta-analysis. To summarize the main findings of the articles, we included the most common complications. We included complications that were reported in 2 or more studies in the analysis. We added together the number of teeth that experienced a specific complication and then divided that figure by the total number of laterally luxated teeth to determine a percentage for the specific complication. JADA 150(8)
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Table 2. Characteristics of included studies.
STUDY Andreasen and Colleagues,15 1985
STUDY DESIGN
SAMPLE SIZE (LATERAL LUXATED MATURE TEETH) FOLLOW-UP TREATMENT
LOCATION
Retrospective Department of Oral and Maxillofacial cohort Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
Ferrazzini Pozzi Prospective and Colleagues,14 cohort 2008
NA*
88
Minimum 5 y, Splinting or no up to 10 y treatment
44
Minimum 4 y
Manual reduction and splinting Manual reduction and splinting
Hecova and Colleagues,13 2010
Retrospective Faculty Hospital, Pilsen, Czech cohort Republic
141
Minimum 5 y
Hermann and Colleagues,12 2012
Retrospective Department of Oral and Maxillofacial cohort Surgery, Copenhagen University Hospital, Rigshospitalet, Denmark
131
Range: 10.8 Manual mo - 22 y reduction and Median: 1.3 y splinting
* NA: Not applicable.
RESULTS There was a total of 637 articles in the search results, and after we removed duplicates, 291 remained. We screened the titles and abstracts and excluded irrelevant studies. We downloaded 28 articles and assessed them for eligibility (Figure). After screening, we included 4 articles.12-15 The included studies were both retrospective and prospective in nature. We excluded 3 studies because the measured outcomes were not differentiated between mature and immature teeth.16-18 Additional characteristics of the included studies are presented in Table 2. Manual reduction in combination with splinting procedures appeared to be the most common course of treatment for lateral luxation injuries in mature teeth (Table 2). We assessed the quality of the studies using the Newcastle-Ottawa Scale (Table 3). Each of the 4 included studies represented the exposed cohort, did not have the outcome of interest at the beginning of the study, and had an adequate follow-up of the study cohort (Table 3). Because the included studies were not randomized controlled trials, the outcomes varied across the studies, and, as a result, we did not attempt a meta-analysis. The results we describe in Table 4 only include outcomes that 2 or more studies shared. After pooling the results, we found that pulp necrosis was the most frequent complication among mature teeth with lateral luxation injuries (44.2%). Surface resorption was the second most frequent complication (14.0%), whereas pulp canal obliteration and inflammatory resorption were less frequent (8.1% and 8.5%, respectively). The least common complication was replacement resorption (0.9%). DISCUSSION The results of this systematic review show the relatively high frequency of complications after lateral luxation injuries are sustained to mature teeth. Pulp necrosis seems to be the most frequent complication (44.2%) but is less common in immature teeth with lateral luxation injury (17.5%).19 The frequency of complications and the type of complications of teeth with lateral luxation varied between the 4 included studies. The included studies consistently reported that replacement resorption was a relatively rare complication of laterally luxated teeth. There was less consistency in the reports on the frequency of pulpal necrosis. Possible explanations for the differences include the different follow-up periods, reporting of different outcomes, and different assessments or tools used for diagnosis. This finding emphasizes the need to follow up frequently with patients to monitor teeth with lateral luxation.1 If pulpal necrosis is not identified and treated early, it can lead to other sequelae such as dental abscesses or resorption that might necessitate tooth extraction. The development of pulpal necrosis in traumatized teeth is influenced by root maturity and delay of treatment.15,20-22 Although less common, other outcomes such as pulp canal obliteration, inflammatory resorption, and surface resorption are possible and should be monitored for at follow-up visits. These findings are unique to mature teeth that have experienced lateral luxation. In a systematic review of the complications that occur from lateral luxation injuries in immature teeth, the authors found that 652
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Table 3. Quality assessment of included studies based on the Newcastle-Ottawa Scale.* STUDY
SELECTION
COMPARABILITY
Demonstration That the Outcome Representative Selection of Interest Was of the Not Present at of the Exposed Nonexposed Ascertainment the Start Cohort Cohort of Exposure of the Study
Comparability of Cohorts Based on Study Design or Analysis
OUTCOME
Adequate Follow-up Adequacy Assessment for of of Outcomes Follow-up Outcome to Occur of Cohorts
Andreasen and Colleagues,13 1985
Y*
NA†
Y
Y
NA
Y
Y
Y
Ferrazzini Pozzi and Colleagues,12 2008
Y
NA
Y
Y
NA
Y
Y
Y
Hecova and Colleagues,11 2010
Y
NA
Unclear
Y
NA
Unclear
Y
Y
Hermann and Colleagues,10 2012
Y
NA
Y
Y
NA
Y
Y
Y
* Y: Yes † NA: Not applicable.
Table 4. Pooled reports of complications of laterally luxated mature teeth.* PULP CANAL OBLITERATION
PULP NECROSIS
SURFACE RESORPTION
INFLAMMATORY RESORPTION
REPLACEMENT RESORPTION
NO COMPLICATIONS
NA†
68 of 88
NA
NA
NA
0 of 88
Ferrazzini Pozzi and Colleagues,12 2008
7 of 44
NA
NA
NA
1 of 44
19 of 44
Hecova and Colleagues,11 2010
8 of 141
89 of 141
1 of 141
21 of 141
1 of 141
40 of 141
NA
2 of 131
37 of 131
2 of 131
1 of 131
0 of 131
15 (185)
159 (360)
38 (272)
23 (272)
3 (316)
59 (404)
8.1
44.2
14.0
8.5
0.9
14.6
STUDY Andreasen and Colleagues,13 1985
Hermann and Colleagues,10 2012 Pooled Incidence No. (N) %
* The number of complications is not mathematically aligned with the number of teeth without complications because some teeth had multiple complications. Furthermore, only complications that were reported in 2 or more studies are included in this table. For example, if only 1 study included marginal periodontal breakdown as a complication, it is not included in this table. † NA: Not applicable.
the most prevalent outcome was pulp canal obliteration (31.3%).19 On the contrary, pulp canal obliteration is a much less common finding in mature teeth (8.1%). Although there are several possible adverse outcomes of lateral luxation injuries, ranging from pulpal necrosis to inflammatory resorption, clinicians should be aware of which complications are most frequent in either mature or immature teeth. The timeline of when to expect these complications also has been studied previously; however, the times at which the complications occur do vary, and thus it is important for clinicians to have frequent follow-ups with patients to detect complications as soon as possible.13 This information will help aid clinicians in making the proper diagnosis at follow-up appointments and performing appropriate treatment interventions such as elective endodontic treatment to prevent future complications. Elective endodontic treatment is an option for dental trauma cases. For lateral luxation injuries specifically, current guidelines suggest monitoring the pulpal condition of the tooth and only performing endodontic treatment if the pulp becomes necrotic.1 However, the decision to perform elective endodontic treatment is based on the patient’s specific situation. The partial evidence in the treatment of dental trauma is a limitation to the current guidelines. Because randomized controlled trials are not ethical in studies of dental trauma, the best available evidence is from cohort studies. Therefore, it becomes critical that the reported JADA 150(8)
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outcomes are homogeneous among studies. Suggestions for these outcomes were published in 2018.23 Using these guidelines will allow for better evidenced-based decisions in the long-term future. In addition to focusing on secondary preventative measures for dental trauma, it is important to consider primary prevention as a priority. After a traumatic dental injury such as lateral luxation has occurred, the patient is at risk of developing a lifetime of possible complications. Therefore, prevention of traumatic dental injuries is key. A call for prevention based on the International Association of Dental Traumatology guidelines was provided by Levin and Zadik.24 This included providing public lectures about the prevention and management of dental trauma, educating all dental staff about emergency management of dental trauma, recognizing patients who are at high risk of experiencing dental trauma, and providing medium solution kits for avulsed teeth in first aid kits at public facilities.24 Despite education efforts, however, compliance is not achieved necessarily, particularly with mouthguard use.25 For example, military populations are at a high risk of experiencing dental trauma.26,27 Although educational efforts have been applied, more official reinforcement may be required to mandate mouthguard use.25 This may apply to all high-risk categories such as contact sports.28,29 The results of this systematic review show that 1 of the most prevalent traumatic dental injuries presents complications. Therefore, serious effort should be made by dental health care professionals to prevent traumatic dental injuries at both the private practice patientclinician level, as well as on a broader public health level. Limitations of this systematic review involve the inclusion of retrospective and prospective cohort studies. The inclusion of such studies presents confounding variables and bias, but the inclusion of randomized controlled trials was not possible. Furthermore, there is the possibility of detection bias because the reported outcomes were not necessarily measured homogeneously across the studies. It should be recognized that the pooled incidence reported in this study is based on heterogeneous studies and that not all reported complications of lateral luxation injuries are reported in Table 4. CONCLUSION This systematic review highlights the relatively high frequency of complications such as pulpal necrosis in permanent teeth with lateral luxation. This reinforces the importance of strict follow-ups of patients with lateral luxation injuries. Furthermore, this systematic review emphasizes the importance of consistent reporting of dental trauma outcomes. Because randomized controlled trials are nearly impossible in the dental trauma field, it is crucial to have well-conducted cohort studies to guide evidenced-based decision making. n
Ms. Clark is a clinical instructor, Division of Periodontology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. Dr. Levin is a professor, Division of Periodontology, Faculty of Medicine and Dentistry, University of Alberta, 5-468 Edmonton Clinic Health
1. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries, 1: fractures and luxations of permanent teeth. Dent Traumatol. 2012;28(1):2-12. 2. Ritwik P, Massey C, Hagan J. Epidemiology and outcomes of dental trauma cases from an urban pediatric emergency department. Dent Traumatol. 2015;31(2):97-102. 3. Arikan V, Sari S, Sonmez H. The prevalence and treatment outcomes of primary tooth injuries. Eur J Dent. 2010;4(4):447-453. 4. Jesus MA, Antunes LA, Risso Pde A, Freire MV, Maia LC. Epidemiologic survey of traumatic dental injuries in children seen at the Federal University of Rio de Janeiro, Brazil. Braz Oral Res. 2010;24(1):89-94. 5. Soporowski NJ, Allred EN, Needleman HL. Luxation injuries of primary anterior teeth-prognosis and related correlates. Pediatri Dent. 1994;16(2):96-101.
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Academy, 11405 - 87 Avenue NW, 5th Floor, Edmonton, AB, Canada T6G 1C9, e-mail [email protected]. Address correspondence to Dr. Levin. Disclosure. Ms. Clark and Dr. Levin did not report any disclosures.
6. Andreasen FM, Andreasen JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations. Endod Dent Traumatol. 1985; 1(5):160-169. 7. Honório HM, de Alencar CRB, Pereira Júnior ES, de Oliveira DSB, de Oliveira GC, Rios D. Posttraumatic displacement management: lateral luxation and alveolar bone fracture in young permanent teeth with 5 years of follow-up. Case Rep Dent. 2015; 634237. 8. Prati C, Pirani C, Zamparini F, Gatto MR, Gandolfi MG. A 20-year historical prospective cohort study of root canal treatments: a multilevel analysis. Int Endod J. 2018;51(9):955-968. 9. Reeves B, Deeks J, Higgins J, Wells G. Including non-randomized studies. In: Cochrane Handbook for Systematic Reviews of Interventions. Chichester, UK: John Wiley & Sons; 2008.
10. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. 11. Wells G, Shea B, O’Connell D, et al. The NewcastleOttawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2009. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford. asp. Accessed December 11, 2016. 12. Hermann NV, Lauridsen E, Ahrensburg SS, Gerds TA, Andreasen JO. Periodontal healing complications following extrusive and lateral luxation in the permanent dentition: a longitudinal cohort study. Dent Traumatol. 2012;28(5):394-402. 13. Hecova H, Tzigkounakis V, Merglova V, Netolicky J. A retrospective study of 889 injured permanent teeth. Dent Traumatol. 2010;26(6):466-475.
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14. Ferrazzini Pozzi EC, von Arx T. Pulp and periodontal healing of laterally luxated permanent teeth: results after 4 years. Dent Traumatol. 2008;24(6):658662. 15. Andreasen FM, Pedersen BV. Prognosis of luxated permanent teeth: the development of pulp necrosis. Endod Dent Traumatol. 1985;1(6):207-220. 16. Oikarinen K, Gundlach KK, Pfeifer G. Late complications of luxation injuries to teeth. Endod Dent Traumatol. 1987;3(6):296-303. 17. Nikoui M, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population, III: lateral luxations. Dent Traumatol. 2003;19(5):280285. 18. Rocha Lima TF, Nagata JY, de Souza-Filho FJ, de Jesus Soares A. Post-traumatic complications of severe luxations and replanted teeth. J Contemp Dent Pract. 2015; 16(1):13-19.
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19. Clark D, Levin L. Prognosis and complications of immature teeth following lateral luxation: a systematic review. Dent Traumatol. 2018;34(4):215-220. 20. Rook WP, Gordon PH, Friend LA, Grundy MC. The relationship between trauma and pulp death in incisor teeth. Br Dent J. 1974;136(6):236-239. 21. Eklund G, Stalhane, Hedegard B. Traumatized permanent teeth in children aged 7-15 years, part III: a multivariate analysis of post-traumatic complications of subluxated and luxated teeth. Swed Dent J. 1976;69(6): 179-189. 22. Magnusson B, Holm AK. Traumatised permanent teeth in children-a follow-up, I: pulpal complications and root resorption. Sven Tandlak Tidskr. 1969;62(2):61-70. 23. Kenny KP, Day PF, Sharif MO, et al. What are the important outcomes in traumatic dental injuries? An international approach to the development of a core outcome set. Dent Traumatol. 2018;34(1):4-11.
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24. Levin L, Zadik Y. Education on and prevention of dental trauma: it’s time to act! Dent Traumatol. 2012;28(1):49-54. 25. Zadik Y, Jeffet U, Levin L. Prevention of dental trauma in a high-risk military population: the discrepancy between knowledge and willingness to comply. Mil Med. 2010;175(12):1000-1003. 26. Zadik Y, Levin L. Oral and facial trauma among paratroopers in the Israel Defense Forces. Dent Traumatol. 2009;25(1):100-102. 27. Zadik Y, Levin L. Orofacial injuries and mouth guard use in elite commando fighters. Mil Med. 2008;173(12): 1185-1187. 28. Levin L, Friedlander LD, Geiger SB. Dental and oral trauma and mouthguard use during sport activities in Israel. Dent Traumatol. 2003;19(5):237-242. 29. Rattai J, Levin L. Oral injuries related to ice hockey in the province of Alberta, Canada: trends over the last 15 years. Dent Traumatol. 2018;34(2):107-113.
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