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Pulpal prognosis following extrusive luxation injuries in permanent teeth with closed apexes
CLINICAL ARTICLES
Pulpal prognosis following extrusive luxation injuries in permanent teeth with closed apexes T h o m D u m s h a , DDS, MS, and Eric J. Hovland, DDS, MEd, MBA
A clinical e v a l u a t i o n of t h e p u l p a l p r o g n o s i s of p e r m a n e n t t e e t h w i t h closed a p e x e s after e x t r u s i v e l u x a t i o n was u n d e r t a k e n . P u l p a l necrosis w a s v e r i f i e d in 51 o f 52 t e e t h in 36 p a t i e n t s a f t e r a p e r i o d t h a t r a n g e d f r o m f o u r w e e k s to 11,~ years.
Extrusive luxation injuries account for approximately 2.6% of all traumatic injuries to the dentition, with subsequent pulpal necrosis as the most common sequela. ',z Andreasen z reported that in a sample of teeth with open and closed apexes, 56 of 88 (64%) showed pulpal necrosis after extrusive luxation injuries. He concluded that pulpal necrosis of all luxation injuries (subluxation, extrusive, and intrusive luxations) depended on the stage of root development, with a greater incidence in teeth with mature apexes. This relationship was not reported for extrusive luxations alone. Eklund, and others 3 examined 69 intrusively and extrusively luxated teeth with mature roots and found 47 teeth (68%) showed pulpal necrosis. Of 29 extrusive and intrusive luxated teeth with immature roots, seven teeth (24%) developed pulpal necrosis. Skieller* reported that, in a sample of six extrusively luxated teeth with closed apexes, two of the teeth responded to electric vitality testing after one to six years, whereas the
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other four teeth remained nonresponsive. The previous studies are few; however, the two larger studies provide data on luxation injuries as a group although not specifically for extrusive luxations. The purpose of this study was to determine the prognosis for pulpal necrosis in extrusively luxated permanent teeth with mature apexes. MATERIALS AND METHODS The sample consisted of 36 patients with 52 extrusively luxated teeth with closed apexes referred to the University of Maryland Dental School from June 1978 to June 1981. Eighty-six percent of the patients were male with the patients' ages ranging from ten to 43 years, and a mean of 20 years (Table). This study defined extrusive luxation as a partial displacement of the tooth out of its socket. 2 All but five of the luxated teeth were stabilized with direct-bonded meshbacked, stainless steel orthodontic brackets attached by elastic ligatures to a stainless steel wire? One tooth was
not splinted and four were splinted with wire ligatures. The splint remained in place for an average of six weeks. Recall examinations were performed periodically, and patients' symptoms as well as percussion, mobility, palpation, radiographic, and electric pulp test findings were recorded. Pulpal necrosis was diagnosed by developing periadicular radiolucent areas, patients' signs, symptoms, and clinical data, or a negative response to the electric pulp test. In all cases, the diagnosis was followed by pulpal access without anesthesia. At the time of access, the diagnosis was clinically verified by lack of pulpal hemorrhage.
RESULTS Fifty-one of 52 teeth disclosed pulpal necrosis verified by lack of hemorrhage during removal of pulp reminants (Table). In one tooth, the patient experienced pain after the pulp chamber was entered and hemorrhage was present.
J O U R N A L OF E N D O D O N T I C S [ VOL 8, NO 9, SEPTEMBER 1982
DISCUSSION The percentage of extrusively luxated permanent teeth, which later showed necrosis (98%), was considerably higher than that found by Eklund and others 3 or Andreasen 2 (68% and 64%, respectively). This variation in results may have resulted from the different variables found in the three studies. The Eklund study 3 reported the incidence of necrosis after extrusive luxation in a population of young patients whose ages ranged from seven to 15 years of age. The authors found an incidence of necrosis in 24% of teeth with immature roots and in 64% of teeth with mature roots, which indicates that root development is a significant factor in the incidences of pulp necrosis after extrusive luxation. The maturity of the roots was determined by radiographic appearance, thus examining only a mesiodistal view of root development. Duell 6 reported that buccoiingual root development is slower than mesiodistal development, so that a radiographically appearing mature root may have closed buccolingually. Duell further stated that, in permanent incisor teeth, the lag between mesiodistal and buccolingual development usually exists for more
than three years after eruption, and in some cases, until 15 years of age. Thus, there is the possibility that the young population (ages 7 through 15) in the Eklund study may have ineluded open or partially open apexes even though the apexes appeared closed radiographically. Our sample, however, consisted of a much older population with the mean age being 20 years; the range of age was from ten to 40 years, with 73% of the sample being older than 15 years. The difference in patient age and root maturity may explain the difference in incidence of pulpal necrosis. Andreasen 2 did not specify the age group of his sample nor did he report separately the incidence of pulpal necrosis in extrusively luxated teeth with closed apexes. On the basis of the Eklund study, however, the number of necrotic teeth with closed apexes would be greater than those with open ones. Another possible variable is the type of injury sustained by our patient population. Although our definition of luxation (partial displacement of the tooth from the socket) is similar to that used by Eklund and others 3 and Andreasen, 7 the definition is sufficiently broad to include mild to severe types of dislocation injuries. Our patient
population consisted mainly of patients treated in the University of Maryland Hospital; thus the severity of injury was probably greater than that normally seen in a dental clinic or office. Because the severity of injuries in previous studies cannot be determined, its significance cannot be evaluated. After the electric pulp tester failed to produce a response, all teeth were opened without anesthesia. In most cases, the teeth including the roots, were either pulpless or totally necrotic. However, in a few cases, there was some hemorrhage at the apical 2 to 3 mm, and in one case, hemorrhage had occurred in the pulp chamber. Interestingly, 86% of the patients were asymptomatic at the time of access. If it were not for the required and thorough follow-up, many of the patients would not have returned nor would the necrotic pulps have been diagnosed. Accordingly, the necessity for routine recall visits for all patients who have had treatment after extrusive luxation injuries is emphasized. Histologically, it has been reported that in replanted or autotransplanted teeth with open apexes, it is possible for teeth that later show at least partially necrotic pulps to generate repair through the ingrowth of well-vascularized connective tissue, s'9 However, in studies that have examined replanted or transplanted teeth with closed apexes in which a limited opening for blood supply exists, the conclusion has been that pulps in these teeth would not be expected to recover or survive the transplantation trauma. 8'~~ The current study, which examined partially and not totally dislocated teeth, clinically supports the concept that teeth with fully mature root development that have been forcefully separated from their blood supply are not expected to recover when replanted in 411
JOURNAL OF ENDODONTICS [ VOL 8, NO 9, SEPTEMBER 1982
their previous position. Dr. Dumsha is an assistant professor, department of endodontics; and Dr. Hovland is an assistant professor, department of endodonties, and director of undergraduate clinics, office of Clinical Affairs, Baltimore College of Dental Surgery, Dental School, University of Maryland at Baltimore. Requests for reprints should be directed to Dr. Dumsha, Department of Endodontics, University of Maryland, 666 W Baltimore St, Baltimore, 21201.
References 1. Hedegard, B., and Stalhane, I. A study of traumatized permanent teeth in children aged 7-15 years. Swed. Dent J 66:43-450, 1973.
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2. Andreasen, J.O. Luxation of permanent teeth due to trauma. A clinical and radiographic follow-up study of 184 injured teeth. Scand J Dent Res 78:273-286, 1970. 3. Eklund, G.; Stalhane, I.; and Hedegard, B. A study of traumatized teeth in children aged 7-15 years. Swed Dent J 69:179-189, 1976. 4. Skieller, V. The prognosis for young teeth loosened after mechanical injuries. Acta Odontol Scand 18:171-181, 1960. 5. Hnvland, E.J., and Gutmann, J.L. Awaumatic stabilization for traumatized teeth. J Endod 2:12:390-391, 1976. 6. Duell, R. Conservative endodontic treatment of the npen apex in three dimensions. Dent Clin Nnrth Am 17:125-134, 1973. 7. Andreasen, J.O. Traumatic injuries to the
teeth. St. Louis, C. V. Mosby, 1972. 8. Ohman, A. Healing and sensitivity to pain in young replanted human teeth. An experimental, clinical, and histologic study. Odontol Tand Skr 73:166-227, 1965. 9. Skoglund, A., and Tronstad, L. Pulpal changes in replanted and autotransplanted immature teeth in dogs. J Endod 7:309-316, 1981. 10. Stanley, H.R., and others. Ishemie infarclion of the pulp. Sequential degenerative changes of the pulp after traumatic injury. J Endod 4:325-335, 1978. 11. Hasselgren, G.; Larsson, A.; and Rundquist, L. Pulpal status after autogenous transplantation of fully developed maxillary canines. Oral Surg 44:106-112, 1977.
Pulpal prognosis following extrusive luxation injuries in permanent teeth with closed apexes T h o m D u m s h a , DDS, MS, and Eric J. Hovland, DDS, MEd, MBA
A clinical e v a l u a t i o n of t h e p u l p a l p r o g n o s i s of p e r m a n e n t t e e t h w i t h closed a p e x e s after e x t r u s i v e l u x a t i o n was u n d e r t a k e n . P u l p a l necrosis w a s v e r i f i e d in 51 o f 52 t e e t h in 36 p a t i e n t s a f t e r a p e r i o d t h a t r a n g e d f r o m f o u r w e e k s to 11,~ years.
Extrusive luxation injuries account for approximately 2.6% of all traumatic injuries to the dentition, with subsequent pulpal necrosis as the most common sequela. ',z Andreasen z reported that in a sample of teeth with open and closed apexes, 56 of 88 (64%) showed pulpal necrosis after extrusive luxation injuries. He concluded that pulpal necrosis of all luxation injuries (subluxation, extrusive, and intrusive luxations) depended on the stage of root development, with a greater incidence in teeth with mature apexes. This relationship was not reported for extrusive luxations alone. Eklund, and others 3 examined 69 intrusively and extrusively luxated teeth with mature roots and found 47 teeth (68%) showed pulpal necrosis. Of 29 extrusive and intrusive luxated teeth with immature roots, seven teeth (24%) developed pulpal necrosis. Skieller* reported that, in a sample of six extrusively luxated teeth with closed apexes, two of the teeth responded to electric vitality testing after one to six years, whereas the
410
other four teeth remained nonresponsive. The previous studies are few; however, the two larger studies provide data on luxation injuries as a group although not specifically for extrusive luxations. The purpose of this study was to determine the prognosis for pulpal necrosis in extrusively luxated permanent teeth with mature apexes. MATERIALS AND METHODS The sample consisted of 36 patients with 52 extrusively luxated teeth with closed apexes referred to the University of Maryland Dental School from June 1978 to June 1981. Eighty-six percent of the patients were male with the patients' ages ranging from ten to 43 years, and a mean of 20 years (Table). This study defined extrusive luxation as a partial displacement of the tooth out of its socket. 2 All but five of the luxated teeth were stabilized with direct-bonded meshbacked, stainless steel orthodontic brackets attached by elastic ligatures to a stainless steel wire? One tooth was
not splinted and four were splinted with wire ligatures. The splint remained in place for an average of six weeks. Recall examinations were performed periodically, and patients' symptoms as well as percussion, mobility, palpation, radiographic, and electric pulp test findings were recorded. Pulpal necrosis was diagnosed by developing periadicular radiolucent areas, patients' signs, symptoms, and clinical data, or a negative response to the electric pulp test. In all cases, the diagnosis was followed by pulpal access without anesthesia. At the time of access, the diagnosis was clinically verified by lack of pulpal hemorrhage.
RESULTS Fifty-one of 52 teeth disclosed pulpal necrosis verified by lack of hemorrhage during removal of pulp reminants (Table). In one tooth, the patient experienced pain after the pulp chamber was entered and hemorrhage was present.
J O U R N A L OF E N D O D O N T I C S [ VOL 8, NO 9, SEPTEMBER 1982
DISCUSSION The percentage of extrusively luxated permanent teeth, which later showed necrosis (98%), was considerably higher than that found by Eklund and others 3 or Andreasen 2 (68% and 64%, respectively). This variation in results may have resulted from the different variables found in the three studies. The Eklund study 3 reported the incidence of necrosis after extrusive luxation in a population of young patients whose ages ranged from seven to 15 years of age. The authors found an incidence of necrosis in 24% of teeth with immature roots and in 64% of teeth with mature roots, which indicates that root development is a significant factor in the incidences of pulp necrosis after extrusive luxation. The maturity of the roots was determined by radiographic appearance, thus examining only a mesiodistal view of root development. Duell 6 reported that buccoiingual root development is slower than mesiodistal development, so that a radiographically appearing mature root may have closed buccolingually. Duell further stated that, in permanent incisor teeth, the lag between mesiodistal and buccolingual development usually exists for more
than three years after eruption, and in some cases, until 15 years of age. Thus, there is the possibility that the young population (ages 7 through 15) in the Eklund study may have ineluded open or partially open apexes even though the apexes appeared closed radiographically. Our sample, however, consisted of a much older population with the mean age being 20 years; the range of age was from ten to 40 years, with 73% of the sample being older than 15 years. The difference in patient age and root maturity may explain the difference in incidence of pulpal necrosis. Andreasen 2 did not specify the age group of his sample nor did he report separately the incidence of pulpal necrosis in extrusively luxated teeth with closed apexes. On the basis of the Eklund study, however, the number of necrotic teeth with closed apexes would be greater than those with open ones. Another possible variable is the type of injury sustained by our patient population. Although our definition of luxation (partial displacement of the tooth from the socket) is similar to that used by Eklund and others 3 and Andreasen, 7 the definition is sufficiently broad to include mild to severe types of dislocation injuries. Our patient
population consisted mainly of patients treated in the University of Maryland Hospital; thus the severity of injury was probably greater than that normally seen in a dental clinic or office. Because the severity of injuries in previous studies cannot be determined, its significance cannot be evaluated. After the electric pulp tester failed to produce a response, all teeth were opened without anesthesia. In most cases, the teeth including the roots, were either pulpless or totally necrotic. However, in a few cases, there was some hemorrhage at the apical 2 to 3 mm, and in one case, hemorrhage had occurred in the pulp chamber. Interestingly, 86% of the patients were asymptomatic at the time of access. If it were not for the required and thorough follow-up, many of the patients would not have returned nor would the necrotic pulps have been diagnosed. Accordingly, the necessity for routine recall visits for all patients who have had treatment after extrusive luxation injuries is emphasized. Histologically, it has been reported that in replanted or autotransplanted teeth with open apexes, it is possible for teeth that later show at least partially necrotic pulps to generate repair through the ingrowth of well-vascularized connective tissue, s'9 However, in studies that have examined replanted or transplanted teeth with closed apexes in which a limited opening for blood supply exists, the conclusion has been that pulps in these teeth would not be expected to recover or survive the transplantation trauma. 8'~~ The current study, which examined partially and not totally dislocated teeth, clinically supports the concept that teeth with fully mature root development that have been forcefully separated from their blood supply are not expected to recover when replanted in 411
JOURNAL OF ENDODONTICS [ VOL 8, NO 9, SEPTEMBER 1982
their previous position. Dr. Dumsha is an assistant professor, department of endodontics; and Dr. Hovland is an assistant professor, department of endodonties, and director of undergraduate clinics, office of Clinical Affairs, Baltimore College of Dental Surgery, Dental School, University of Maryland at Baltimore. Requests for reprints should be directed to Dr. Dumsha, Department of Endodontics, University of Maryland, 666 W Baltimore St, Baltimore, 21201.
References 1. Hedegard, B., and Stalhane, I. A study of traumatized permanent teeth in children aged 7-15 years. Swed. Dent J 66:43-450, 1973.
412
2. Andreasen, J.O. Luxation of permanent teeth due to trauma. A clinical and radiographic follow-up study of 184 injured teeth. Scand J Dent Res 78:273-286, 1970. 3. Eklund, G.; Stalhane, I.; and Hedegard, B. A study of traumatized teeth in children aged 7-15 years. Swed Dent J 69:179-189, 1976. 4. Skieller, V. The prognosis for young teeth loosened after mechanical injuries. Acta Odontol Scand 18:171-181, 1960. 5. Hnvland, E.J., and Gutmann, J.L. Awaumatic stabilization for traumatized teeth. J Endod 2:12:390-391, 1976. 6. Duell, R. Conservative endodontic treatment of the npen apex in three dimensions. Dent Clin Nnrth Am 17:125-134, 1973. 7. Andreasen, J.O. Traumatic injuries to the
teeth. St. Louis, C. V. Mosby, 1972. 8. Ohman, A. Healing and sensitivity to pain in young replanted human teeth. An experimental, clinical, and histologic study. Odontol Tand Skr 73:166-227, 1965. 9. Skoglund, A., and Tronstad, L. Pulpal changes in replanted and autotransplanted immature teeth in dogs. J Endod 7:309-316, 1981. 10. Stanley, H.R., and others. Ishemie infarclion of the pulp. Sequential degenerative changes of the pulp after traumatic injury. J Endod 4:325-335, 1978. 11. Hasselgren, G.; Larsson, A.; and Rundquist, L. Pulpal status after autogenous transplantation of fully developed maxillary canines. Oral Surg 44:106-112, 1977.