dental trauma

The outcome of traumatic events involving teethdepends on three factors: the extent of injury, the qual-ity and timeliness of initial care, and the follow-upevaluation and care.

The extent of injury is influenced by the severity ofthe traumatic event1 and the presence or absence of pro-tective gear such as mouthguards, face shields, airbags,and seatbelts.2 Direction of force against the teeth andsupporting structures and the type of impact—blunt orsharp—also can determine how much tissue damagewill result. It is well recognized that preventive measuressuch as tooth and face protection during sporting eventsand seatbelts and airbags used in cars can significantlyreduce the severity of injuries.2

The quality and timeliness of initial care contributeto a desirable outcome by promoting healing. A goodexample is the avulsed tooth: if it is replanted withinthe first few minutes after avulsion, the prognosis isgood, with a high rate of success.3 It is important tonote, however, that the quality of initial care also isimportant. As Andreasen has pointed out, the initialtreatment should not add more trauma to alreadyinjured tissues.4 A good example of this principle iswith respect to luxated teeth: the repositioning of dis-placed teeth and adjacent tissues must be done verygently to promote desirable wound healing and long-term favorable outcome.

Follow-up evaluation and care are important com-ponents of long-term successful outcomes.1 A replant-ed avulsed tooth may show an excellent initialresponse—healing of the severed periodontal liga-ment—but if the necrotic pulp is allowed to harborbacteria, the resultant root resorption will lead to lossof the tooth. Often the long-term outlook for a trau-matized tooth is related to the response of the tooth’spulp—thus the importance of endodontic considera-tions in dental trauma.

This chapter contains information both on thepreservation, when indicated, of pulp vitality after atraumatic injury and the appropriate endodontic inter-vention when pulp necrosis is present or expected.

ETIOLOGY AND INCIDENCE

Sudden impact involving the face or head may result intrauma to the teeth and supporting structures. Themost frequent causes are falling while running, fol-lowed by traffic accidents, acts of violence, and sports.5

Automobile accidents are often very destructive.One estimate suggests that 20 to 60% of all traffic acci-dents produce some injury to the facial regions. Whensuch injuries involve teeth, avulsions or intrusions arethe most common sequelae.6 Sports activities, bothteam and individual, can lead to dental injuries, whichhave been shown to be common in high school athleteswho do not use mouthguards.7

The incidence of dental trauma continues to beinvestigated. A large US study indicated that 25% of thepopulation 6 to 50 years of age may have sustainedtraumatic injuries to the anterior teeth.8 Surprisingly,some are unaware of their dental injuries, and manychoose not to seek dental treatment.

Most dental injuries occur during the first twodecades of life. The most accident-prone time period isfrom ages 8 to 12 years. Frequent dental injuries alsooccur from ages 2 to 3 years.5 As might be expected,boys tend to injure their teeth more frequently thangirls, by ratios varying from 2:1 to 3:1. One exception isin the preschool age, during which time little genderdifference is noted.5 Maxillary central incisors, fol-lowed by maxillary lateral incisors and then themandibular incisors, are the teeth most frequentlyinvolved.5 The most commonly observed dental trau-ma involves fracture of enamel, or enamel and dentin,but without pulp involvement.5

Chapter 15

ENDODONTIC CONSIDERATIONS IN DENTAL TRAUMA

Leif K. Bakland

Finally, it is becoming apparent that dental injuries canresult from child abuse or “battered child syndrome.” Thedentist may be the first health care provider to observepediatric injuries resulting from abuse. More than half ofthe reported cases of child abuse include evidence of oro-facial trauma. Many of these unfortunate children haveintraoral injuries, such as tooth and jaw fractures. It is theresponsibility of all professionals to report suspectedcases of child abuse or neglect.9

The following observations have been recommend-ed as possible indicators of an abused child; none, how-ever, are pathognomonic, and the absence of any ofthem does not preclude the diagnosis of abuse10:

1. There is a delay in seeking medical (dental) help (orhelp is not sought at all).

2. The story of the “accident” is vague, is lacking indetail, and may vary with each telling and from per-son to person.

3. The account of the accident is not compatible withthe injury observed.

4. The parents’ mood is abnormal. Normal parents arefull of creative anxiety for the child, whereas abusingparents tend to be more preoccupied with their ownproblems—for example, how they can return homeas soon as possible.

5. The parents’ behavior gives cause for concern—forexample, they may become hostile and rebut accusa-tions that have not been made.

6. The child’s appearance and interaction with the par-ents are abnormal. The child may look sad, with-drawn, or frightened.

7. The child may say something concerning the injurythat is different from the parents’ story.

Most hospitals have personnel who can offer adviceto health care providers unsure about how to reportsuspected abuse.

CLASSIFICATION

The purpose of classifying dental injuries is to pro-vide a description of specific conditions, allowingdentists to recognize and treat using recommendedtreatment remedies. It also allows data collectionworldwide to monitor many aspects of dental trau-matology: etiology, incidence, and treatment out-come. The currently recommended classification isone based on the World Health Organization classifi-cation of diseases and modified by Andreasen andAndreasen.5 This classification is used by theInternational Association of Dental Traumatologyand is preferred over previous outdated systems.11 It

796 Endodontics

is also the classification that will be followed in thischapter (Table 15-1).

EXAMINATION

Patients with dental injuries should be examined assoon after the traumatic incident as possible.12,13 Theexamination process of trauma patients is similar to theregular examination of all endodontic patients, asdescribed in chapter 6. However, owing to the possibili-ty of concomitant injury to adjacent tissues and the fre-quent need to provide insurance and/or a legal report, itis prudent to pay particular attention to a careful exam-ination and recording of clinical findings. For that rea-son, the following sections have been given emphasis.

History

The clinical dental history is primarily the subjectivestatement by the patient. It includes the chief com-plaint, history of the present illness (injury), and perti-nent medical history.

Chief Complaint

The chief complaint may appear obvious in traumaticinjuries. However, the patient should be asked aboutsevere pain and other significant symptoms. A bloodylip appears more dramatic, but a concomitant broken

Table 15-1 Dentofacial Injuries

Soft tissuesLacerationsContusionsAbrasions

Tooth fracturesEnamel fracturesCrown fractures—uncomplicated (no pulp exposure)Crown fractures—complicated (with pulp exposure)Crown-root fracturesRoot fractures

Luxation injuriesTooth concussionSubluxationExtrusive luxationLateral luxationIntrusive luxationAvulsion

Facial skeletal injuriesAlveolar process—maxilla/mandibleBody of maxillary/mandibular boneTemporomandibular joint

Endodontic Considerations in Dental Trauma 797

jaw may produce more pain and must be considered ahigher priority. The chief complaint may include sever-al subjective symptoms, and these should be listed inorder of importance to the patient. Also note the dura-tion of each symptom.

History of Present Illness (Injury)

Obtain information about the accident in chronologicorder and determine what effect it has had on thepatient. Note any treatment before this examinationand question the patient about previous injuriesinvolving the same area. The information can be gath-ered by using questions such as the following:

• When and where did the injury happen? Record thetime and date as closely as the patient can recall.Note the location, for example, playground, car acci-dent, etc. All of this may be highly pertinent if legalor insurance problems later develop.

• How did the injury happen? This question can pro-vide important information. A blow to the face by ablunt object, such as a fist, often produces a differentinjury than if the chin is hit during a car accident orif the patient falls off a bicycle.14 Further, since chil-dren with “battered child syndrome” may be seen, ahigh degree of suspicion should be maintained incases with a marked discrepancy between the clinicalfindings and the history supplied by the parent orguardian.10,11

• Have you had treatment elsewhere before cominghere? Prior treatment affects both the treatmentplan and the prognosis. If the tooth was avulsed, wasit replanted immediately or how soon after the acci-dent? Was it washed?

• Have you had similar injuries before? Repeatedinjuries to teeth affect the pulps and their ability torecover from trauma. Previous trauma may alsoexplain clinical findings not in harmony with thedescription of the most recent injury. This is partic-ularly true of abused children.

• Have you noticed any other symptoms since theinjury? This type of question can provide very usefulinformation about the possible effects of the injury onthe nervous system. Signs and symptoms to watch forare dizziness; vomiting; severe headaches; seizures orconvulsions; blurred vision; unconsciousness; loss ofsmell, taste, hearing, sight, or balance; or bleedingfrom the nose or ears. Affirmative response to any ofthe above indicates the need for emergency medicalevaluation.12

• What specific problems have you had with the trau-matized tooth/teeth? Pain, mobility, and occlusal

interference are the most commonly reported symp-toms. In addition, the patient should be asked aboutany symptoms from adjacent soft tissues such astongue, lips, cheeks, gingiva, and alveolar mucosa.

Medical History

The following aspects of the medical history areemphasized for their importance in trauma cases:

1. Allergic reactions to medications. Because bothantibiotics and analgesics are frequently prescribedfor trauma patients, it is necessary to know if thepatient can tolerate the prescribed medication.

2. Disorders, such as bleeding problems, diabetes, andepilepsy. These are only some of the many physicaland medical conditions that may affect the manage-ment of a trauma patient. Because patients withmedical problems sometimes neglect to note such adisorder on the questionnaire, the dentist may haveto question in more depth. Patients suffering fromgrand mal epilepsy, for example, may have telltalechipped or fractured teeth that were injured duringseizures.

3. Current medications. To avoid unwanted druginteractions, the dentist must know which drugs thepatient is currently taking, including over-the-counter medications.

4. Tetanus immunization status. For clean wounds, nobooster dose is needed if no more than 10 years haveelapsed since the last dose. For contaminatedwounds, a booster dose should be given if more than5 years have elapsed since the last dose.15

Clinical Examination

A careful, methodical approach to the clinical examina-tion will reduce the possibility of overlooking or miss-ing important details. The following areas should beexamined.

Soft Tissues

Soft tissue trauma, for the most part, is not covered inthis chapter, at least not in regard to treatment, such assuturing. It is important, however, to examine all softtissue injuries because it is not unusual for tooth frag-ments to be buried in the lips. The radiographic exam-ination should include specific exposures of the lipsand cheeks if lacerations and fractured teeth are pres-ent (Figure 15-1). In any event, all areas of soft tissueinjury should be noted, and the lips, cheeks, and tongueadjacent to any fractured teeth should be carefullyexamined and palpated.

Facial Bones

The maxilla, mandible, and temporomandibular jointshould be examined visually and by palpation, seekingdistortions, malalignment, or indications of fractures.Indications of possible fractures should be followed upradiographically. Also note possible tooth dislocation,gross occlusal interference, and development of apicalpathosis.

Teeth

The teeth must be examined for fractures, mobility,displacement, injury to periodontal ligament and alve-olus, and pulpal trauma. Remember to examine theteeth in the opposite arch also. They, too, may havebeen involved to some degree.

Tooth Fracture

The crowns of the teeth should be cleaned and exam-ined for extent and type of injury. Crown infractions orenamel cracks can be detected by changing the light

798 Endodontics

beam from side to side, shining a fiber-optic lightthrough the crown, or using disclosing solutions.

If tooth structure has been lost, note the extent ofloss: enamel only, enamel and dentin, or enamel anddentin with pulp exposure. Further, indicate the exactlocation on the crown, such as the “distal-incisal cor-ner” or the “incisal one-third horizontal.” Such infor-mation can be useful if you are called on later todescribe the injury. Photographs are very useful as partof the patient record.12

If a crown fracture extends subgingivally, the frac-tured part often remains attached but loose. Also checkfor discoloration of the crown or changes in translucen-cy to fiber-optic light. Both may indicate pulp changes.

Mobility

Examine the teeth for mobility in all directions, includ-ing axially. If adjacent teeth move along with the toothbeing tested, suspect alveolar fracture. Root fracturesoften result in crown mobility, the degree depending on

Figure 15-1 A, Lacerated lips and cheeks should be radi-ographed for embedded tooth fragments. B, Radiographplaced lingual to the lower lip exposed about one half thatused for teeth and shows a hard tissue fragment embedded inthe lip. C, Lateral film also demonstrates a tooth fragment inthe lip (arrow).

A

C

B


the proximity of the fracture to the crown. The degreeof mobility can be recorded as follows: 0 for no mobil-ity, 1 for slight mobility, 2 for marked mobility, and 3for mobility and depressibility. Examine for and recordthe depths of any periodontal pockets.

Displacement

Note any displacement of the teeth that may be intru-sive, extrusive, or lateral (either labial or lingual) orcomplete avulsion. Sometimes the change is minimal,and the patient should be asked about any occlusalinterference that developed suddenly. In occlusalchanges, consider the possibility of jaw or root frac-tures or extrusions.

Injury to Periodontal Ligament and Alveolus

The presence and extent of injury to the periodontalligament and supporting alveolus can be evaluated bytooth percussion. Include all teeth suspected of havingbeen injured and several adjacent and opposing ones.The results may be recorded as “normal response,”“slightly sensitive,” or “very sensitive” to percussion.Careful tapping with a mirror handle is generally satis-factory. In cases of extensive apical periodontal dam-age, however, it may be advisable to use no more than afingertip for percussion. Normal, noninvolved teethshould be included for comparison.

In impact trauma with no fractures or displacement,the percussion test is very important. In some appar-ently undamaged teeth, the neurovascular bundle,entering the apical canal, may have been damaged, andthe possibility of subsequent pulp degeneration exists.Such teeth are often sensitive to percussion.

Pulpal Trauma

The condition of the dental pulp should be evaluatedboth initially and at various times following the trau-matic incident. The response of the pulp to traumalargely determines the treatment of and prognosis forinjured teeth. Often the initial treatment may be notreatment but rather monitoring of the pulp response.Pulps may deteriorate and become necrotic months oryears after the original trauma, so periodic re-evalua-tion is important in the management of dentalinjuries.1

Several means of evaluating traumatized pulps areavailable.1,12 The electric pulp test (EPT) has beenshown as reliable in determining pulpal status, that is,in differentiating between vital and necrotic pulps. TheEPT should be used, and the results recorded, at theinitial visit and at subsequent recall visits. Often, afteran impact injury, the pulp does not respond to the EPT

for some time. But when the pulp recovers, its sensitiv-ity to the EPT gradually returns. Such recovery can bemonitored with the test. Other times, the pulp laterbecomes necrotic after initially responding positivelyor even after apparent recovery from the initial injury.The EPT can provide much useful information if itsadvantages, as well as its limitations, are considered.

Cold stimulus in the form of carbon dioxide or ice isused extensively for pulp testing and is quite reliable.The response, however, is not easily quantified. Theusefulness of cold is most applicable in differentiatingbetween reversible and irreversible pulpitis. Hot stimu-lus has limited use in pulp testing traumatically injuredteeth. However, subjective symptoms can be useful,particularly a history of spontaneous pain, indicatingirreversibility.

Discoloration, particularly a grayish hue, involvingpermanent teeth is indicative of pulp necrosis, whereasa yellowish hue means that extensive calcification hasoccurred. The latter is not necessarily associated withirreversible pulpitis or pulp necrosis.16,17

Radiographic Examination

Radiography is indispensable in the diagnosis andtreatment of dental trauma. Detection of dislocations,root fractures, and jaw fractures can be made by radi-ographic examination. Extraoral radiography is indi-cated in jaw and condylar fractures or when one sus-pects trauma to the succedaneous permanent teeth byintruded primary teeth. Soft tissue radiographic evalu-ation is indicated when tooth fragments or possibleforeign objects may have been displaced into the lips,for example see Figure 15-1. The film should be placedbetween the lip and the jaw, and short exposure at min-imal KVP is advocated.12

The size of the pulp chamber and the root canal, theapical root development, and the appearance of theperiodontal ligament space may all be evaluated byintraoral radiographs. Such films are of prime impor-tance both immediately after injury and for follow-upevaluation.18 Changes in the pulp space, both resorp-tive and calcific, may suggest pulp degeneration andindicate therapeutic intervention (Figure 15-2). Otherradiographic views may be indicated in more extensiveinjuries than those confined to the dentition. Finally, itis also important to carefully file all radiographs forfuture references and comparisons.

Follow-up Evaluation

Trauma patients should be evaluated often enough,and over a long enough period of time, either to deter-mine that complete recovery has taken place or to

detect as early as possible pulpal deterioration and rootresorption. If pulpal recovery (eg, revascularization) isto be monitored, frequent initial re-evaluations (every3 to 4 weeks for the first 6 months) and then yearly arerecommended.1,11 Radiographs and pulp testingshould be included in the evaluations. If inflammatoryresorption or pulp necrosis occurs, endodontic treat-ment is indicated immediately (Figure 15-3). In per-manent teeth, pulp necrosis should be suspected in thepresence of a graying crown discoloration, no responseto the EPT, and radiographic indication of apical peri-odontitis. A lack of response to the EPT alone is notsufficient to diagnose pulp necrosis and recommendpulpectomy.19

Root canal therapy may be indicated if the pulp lumendiminishes at a rapid pace, as determined by radiographstaken at frequent intervals. No general agreement exists,however, about this indication for treatment.19

Examination of Old Injuries

At times, patients request treatment of dental condi-tions, the etiology of which is uncertain. For instance,an anterior tooth with no restorations and no loss oftooth structure may develop symptoms of pulp necro-sis and apical periodontitis (Figure 15-4). Some

800 Endodontics

patients may not remember any traumatic incidents,whereas others may recall specific accidents but onlyafter lengthy efforts at memory recall or after discus-sions with their families. Some may have received treat-ment at the time of injury but somewhat later devel-oped new symptoms. In this case, the dental historyand chief complaint will be related to the currentsymptoms.

Information suggesting previous trauma as the eti-ology would include crown discoloration, gingivaldehiscence, reduced pulp canal lumen, root resorption,

Figure 15-2 Subsequent to trauma one central incisor (a) showspulpal calcification, whereas the adjacent one (b) undergoes inter-nal resorption (arrow). The latter requires endodontic intervention,whereas pulpal calcification in and of itself does not.

Figure 15-3 Extensive resorption (arrow) following trauma. Suchdestructive results can often be minimized by timely endodonticintervention.

A

B


and pulp necrosis not related to other obvious causessuch as caries and/or tooth infractions. Sinus tracts aresometimes the first indication of a previous injury;these tracts should be traced to identify areas of origin(Figure 15-5).

TRAUMATIC INJURIES

Soft Tissue Injuries

Description. Injuries to oral soft tissues can be lacer-ations, contusions, or abrasions of the epithelial layer or acombination of injuries.1 If treatment is indicated, it con-sists of controlling bleeding, repositioning displaced tis-sues, and suturing. Oral soft tissues heal rather quickly.

Tooth Fractures

This category of injuries includes all fractures fromenamel infractions to complicated crown-root frac-tures. They are the most commonly reported types ofdental injuries, with an incidence of 4 to 5% of thepopulation (United States)8,20 accounting for over one-third of all dental trauma.21

Enamel Fractures

Description. Enamel fractures include chips andcracks confined to the enamel and not crossing theenamel-dentin border. These enamel infractions22 canbe seen by indirect light or transillumination or by the

Figure 15-4 Maxillary left central incisor developed an apical abscess30 years after a traumatic basketball accident. A, Note labial swelling(open arrows) and B, apical radiolucency. Pulp did not respond to anelectric pulp test, and the crown was slightly discolored.

Figure 15-5 A, Fistulous tract traced with gutta-percha pointfrom labial orifice to B, apical lesion.

A A

B B

use of dyes. In anterior teeth, the enamel chips ofteninvolve either the mesial or distal corners or the centrallobe of the incisal edge.22

When treatment is indicated, it involves minorsmoothing of rough edges or adding some compositeresin using the acid-etch technique. One other consider-ation needs mentioning. Since it is difficult to predict thelong-term pulpal response to trauma, pulp vitality testsshould be performed both immediately after the injuryand again in 6 to 8 weeks.22 It must be kept in mind that,even with minor traumatic injuries, such as enamel frac-tures, damage to the apical neurovascular bundle mayhave occurred (Figure 15-6). The prognosis, however, forteeth with enamel fractures is very good.22

Crown Fractures—Uncomplicated (No Pulp Exposure)

Description. Crown fractures involving enameland dentin without pulp exposure are called uncompli-cated crown fractures by Andreasen5 and Class 2 frac-tures by Ellis.23 They may include incisal-proximal cor-ners, incisal edges or lingual “chisel”-type fractures inanterior teeth, and, frequently, cusps in posterior teeth.Cusp fractures in posterior teeth are often related toblows to the face. Because anterior teeth are more ofteninvolved in traumatic injuries, the description in thischapter will refer only to these teeth.

Crown fractures that expose dentinal tubules maypotentially lead to contamination and inflammation ofthe pulp. The outcome may be either formation of irri-tational dentin or pulp necrosis. Which outcomeoccurs depends on a number of factors: proximity ofthe fracture to the pulp, surface area of dentin exposed,age of the patient (pulp recession and size of dentinaltubules), concomitant injury to the pulp’s blood sup-ply, length of time between trauma and treatment, andpossibly the type of initial treatment performed.1, 22

Incidence. The enamel/dentin type of crown frac-ture is a very common type of injury; a distinction,however, is not always made between fractures involv-ing only enamel and those involving both enamel anddentin. The two groups together certainly comprise thevast majority of dental injury cases.8,20,21

Diagnosis. The diagnosis of crown fracture with-out pulp involvement is made by clinical examinationwith a mirror and an explorer. In addition, it is alsoimportant to determine the status of the pulp and peri-radicular tissues by the usual examination procedures.

Treatment. The primary goal of treatment in teethwith crown fractures is to protect the pulp by sealingthe dentinal tubules.24 The most effective method is bydirect application of dentin bonding agents and bond-

802 Endodontics

ed restorations. Placement of unsightly stainless steelor temporary acrylic crowns is now a thing of the pastfor enamel/dentin fractures.

Figure 15-6 Sequelae to injury that initially produced only anenamel fracture, A, but includes, in part B, pulpal necrosis, arrestedroot development, and apical periodontitis. Note crown discol-oration in A, visible in transmitted light (arrow)

A

B


If the fractured crown fragment is available, it is oftenadvantageous to use it to restore the tooth. The tech-nique for reattachment (Figure 15-7) is as follows25–27:

Anesthetize the tooth and place a rubber dam to iso-late the tooth. Clean the tooth segment and fracturedtooth with pumice and water. Determine the reattach-ment path of insertion, using a sticky wax handle tohold the coronal fragment. Care should be taken toaccurately refit the fragment since it can easily be mis-aligned anteroposteriorly. Apply a suitable etchant,according to its manufacturer’s directions, to both thetooth and the coronal segment extending 2 mm beyondthe cavosurface margins. Rinse well. Apply a dentinalprimer followed by application of an unfilled resin.Next, dilute a light-cured composite resin with unfilledresin to a creamy consistency and apply it to the tooth

and coronal fragment. Carefully re-insert the fragmentonto the tooth, taking care that the path of insertion iscorrect. Remove excess resin and apply the curing lightcircumferentially. (Alternatively, a dual-cure resin lut-ing agent may be used.) Polish the resin and check theorclusion, which can be adjusted if necessary.

The expected outcome is usually good, althoughresistance to refracture is about 50% less than an intacttooth’s resistance.25

Early treatment of crown fractures is desirable. Thelength of time between injury and treatment has adirect adverse effect on the pulp’s ability to survive.The closeness of the fracture to the pulp and the sizeof the dentinal tubules also have a bearing on thepulp’s continued vitality, the latter being significant inyoung patients.1,22

Figure 15-7 A, Uncomplicated fracture, central incisor. The dentin has been temporarily covered with glass ionomer. B, Radiograph, show-ing fracture with incisal glass ionomer. C, The incisal tooth fragment, which had been kept in water for several days, has been bonded to thetooth after removal of the glass ionomer. D, The tooth as it appears 21⁄2 years after incisal fragment reattachment. (Courtesy of Dr. MitsuhiroTsukiboshi.)

A B

C D

Follow-up and Prognosis. As with most traumaticinjuries, patients with crown fractures need to be re-evaluated periodically to determine pulpal status.Traumatized teeth can develop pulp necrosis sometime after the initial injury, and if necrosis occurs,endodontic therapy is indicated.22

The prognosis is usually good for teeth with crownfractures in which the pulps are not exposed.1,22 Theunpredictable part is determining the extent of con-comitant pulp injury.

Primary Teeth. Crown fractures are rare in theprimary dentition, but when they occur, the pulps areexposed more often than in the permanent dentition.When the pulps are not exposed, treatment consists ofsmoothing rough edges or repairing with compositeresin by the acid-etch technique.22

Crown Fractures—Complicated (With Pulp Exposure)

Description. Crown fractures involving enamel,dentin, and pulp are called complicated crown frac-tures by Andreasen and Andreasen22 and Class 3 frac-tures by Ellis and Davey.23 The degree of pulp involve-ment varies from a pinpoint exposure to a total unroof-ing of the coronal pulp.

The exposure of the pulp in complicated crown frac-tures makes the treatment more difficult. Bacterial con-tamination of the pulp precludes healing and repairunless the exposure can be covered to prevent furthercontamination. The initial reaction is hemorrhage at thesite of the pulp wound. Next, a superficial inflammatoryresponse occurs, followed by either a destructive(necrotic) or proliferative (“pulp polyp”) reaction.28

Incidence. It is fortunate, considering the treat-ment complications, that crown fractures exposing thepulps are far less common than those not involving thepulp. The incidence, compared with all types of dentalinjuries, ranges from 2 to 13%.22

Diagnosis. The diagnosis of crown fracture withpulp involvement can be made by clinical observation.In addition, it is important to determine the conditionof the pulp. If the tooth has been luxated in addition tothe crown fracture, pulpal recovery is compromised,and the longer the pulp is exposed before being pro-tected, the poorer the prognosis for pulpal survival.22

Treatment. Traditionally, these injuries have oftenresulted in automatic pulp extirpation, even in young,developing teeth. Such drastic measures are not alwaysnecessary; vital pulp therapy preserves the potential forcontinued root development—an important consider-ation in a tooth with a thin, weak root structure owingto a lack of complete tooth development.

804 Endodontics

Treatment planning is influenced by tooth maturityand extent of fracture. Every effort must be made topreserve pulps in immature teeth. Conversely, inmature teeth with extensive loss of tooth structure,pulp extirpation and root canal therapy are prudentbefore post/core and crown restoration.

Pulp preservation by vital pulp therapy includes pulpcapping and pulpotomy. Both procedures permit preser-vation of pulp tissue for continued root development.

Pulp capping is a time-honored procedure that issometimes quite successful. However, in recent years, amodified pulpotomy technique (“Cvek type”)29 hasshown itself to be more predictable. This pulpotomytechnique may be termed “shallow pulpotomy” in con-trast to the older method of removing coronal pulp tis-sue deeply to the cervical, or deeper, level. The “deeppulpotomy” techniques were difficult technically andfailed to deliver what vital pulp therapy should: preser-vation of pulp tissue in the critical cervical area of thetooth, where subsequent fractures can occur in thin,weak walls of pulpless teeth.

The procedure for shallow pulpotomy (also referredto as a partial or “Cvek-type” pulpotomy) can be per-formed by any well-trained dentist30,31 (Figures 15-8and 15-9). After anesthesia and rubber dam isolation,remove granulation tissue from the exposure site usinga spoon excavator. This permits evaluation of the sizeof exposure. Next, with a water-cooled, round diamondstone, remove pulp tissue from the pulp proper, to adepth of 1 to 2 mm. Visualize the removal, layer bylayer, rather than a quick cut with the stone. Allowplenty of coolant water spray to irrigate and preventheat damage to the subjacent pulp tissue.

After preparing the pulp tissue, rinse the wound withsaline and allow the bleeding to stop (a cotton pelletmoistened with saline can be used to control the bleed-ing), then wash the wound gently with saline, and it isready for coverage with a calcium hydroxide material.

Apply the calcium hydroxide over the wound andalso cover all exposed adjacent dentin. A hard-settingcalcium hydroxide such as Dycal (Dentsply/Caulk,Tulsa, Okla.) is easy to use. Next, an intermediate baseof hard-setting zinc phosphate cement or glassionomer cement is placed before restoring with dentinadhesive and composite resin.

After radiographic evidence of mineralization ofthe exposed pulpal area, it is recommended that theinitial filling and liner be replaced to preventmicroleakage. This may occur 6 to 12 months after theinitial treatment.29,30

An alternative to the use of calcium hydroxide is anew material, mineral trioxide aggregate (MTA)


Figure 15-8 Shallow pulpotomy. A, Crown fracture exposes pulp. B, Remove pulp tissue with a round diamond bur to a depth of about2 mm; use water spray to cool the diamond. C, After bleeding has stopped, wash the pulp wound with saline and apply a calcium hydrox-ide liner on top of which a base must be placed. The base can be glass ionomer cement. D, The lost tooth structure is replaced with acid-etched composite resin.

A B

DC

806 Endodontics

Figure 15-9 A, Crown fracture exposing pulp. B, Patient’s age (10 years) and stage of root development (open apex) indicate need forperserving radicular pulp. C and D, Pulpotomy and calcium hydroxide to cervical level. E, Acid-etched composite restoration. (Restorationby Dr. James Dunn.) F, Radiograph taken years after accident. Note continued root development (arrow).

A

B

C

D

FE


(ProRoot MTA, Tulsa Dental/Dentsply, Tulsa, Okla.),which has found many uses in endodontics.32 It hasbeen shown to be very effective in vital pulp thera-py33–36 (Figure 15-10).

The technique for managing a traumatic pulp expo-sure using MTA is in many ways similar to that used withcalcium hydroxide, with some minor modifications:

1. The tooth must be anesthetized and should be iso-lated with a rubber dam.

2. The tooth, fractured surface, and wound area shouldbe disinfected using a solution such as sodiumhypochlorite.

3. A shallow pulpotomy is done to provide space forthe MTA. A round diamond stone is used in a high-speed handpiece with water irrigation to removeexposed pulp tissue to a depth of at least 2 mm into

the pulp proper. Bleeding is allowed to stop (whichusually takes 2 to 3 minutes) before MTA is placeddirectly into the pulp wound. The presence of asmall amount of blood in the wound area is not acontraindication to placing MTA; in fact, somemoisture is required for the proper curing of thematerial.

4. Since access is not a problem when performing ashallow pulpotomy, the placement of MTA is not asdifficult as it often can be when used for other pur-poses, such as repair of perforations. The mixture ofMTA powder and liquid should be of such a consis-tency that it can be carried from the mixing pad tothe pulp wound using a dental instrument such as aspoon excavator. A small amount of MTA should beplaced on the wound surface and gently tapped witha moist cotton pellet so that it covers the exposed

Figure 15-10 A, Complicated crown fractures withpulp exposure in both central incisors. B, Radiographshows immature, developing roots with wide openapices. Shallow pulpotomy was done on both teeth,using mineral trioxide aggregate to protect the underly-ing pulp. C, Radiograph taken 2 years later shows excel-lent continued root formation in both teeth. D, Threeyears after vital pulp therapy.

A

CB D

pulp. Next, the entire access into the pulp should befilled in a similar manner using small amounts ofMTA. Any excess moisture should be removed fromthe surface of the MTA using a dry cotton pellet.

5. The rubber dam can then be removed, and thepatient can be dismissed. Leaving the MTA exposedto saliva will allow it to cure. A minimum of 6 hoursshould be allowed for the material to adequatelycure, but clinical experience indicates that waiting atleast 24 hours is better. The tooth can then berestored with a definitive restoration.

Previous research34,35 has shown that the pulpresponds favorably to the protection provided by an MTAlayer. The reparative dentin is consistently more uniformand thicker under MTA compared with calcium hydrox-ide. As has been convincingly demonstrated,37 the pulpcan tolerate almost any dental material and produce newdentin as long as it can be protected against microleakage,a function that MTA appears to perform better than anymaterial with which it has been compared.

The differences in the vital pulp therapy techniquewhen MTA is used in place of calcium hydroxide areimportant to consider. First, it is not important that thepulp wound bleeding be completely stopped prior toplacing the MTA; in fact, the presence of a smallamount of blood provides necessary moisture for cur-ing of the material and has been shown to work as wellas any other fluid.38 Second, since the MTA needs tocure prior to placement of a definitive restoration, it isnecessary to schedule two appointments for this proce-dure: the first to perform the shallow pulpotomy andplace the MTA on the pulp wound and the second tocomplete the restoration after the material has cured.Future material development may be expected to resultin a faster-curing MTA. Third, it is not necessary to re-enter the pulpotomy site later to remove the pulp cap-ping material, as has been recommended for calciumhydroxide pulpotomies.29,30 Mineral trioxide aggregatedoes not appear to deteriorate and disintegrate withtime; thus, space for microleakage does not develop asit does with calcium hydroxide.

In mature, fully developed teeth, particularly thosetreatment planned for full-crown coverage, conven-tional root canal therapy is the treatment of choice. Itshould be pointed out that shallow pulpotomies can beperformed in mature teeth, thus preserving pulp tissueand accomplishing repair quite conservatively. But itshould probably be reserved for instances of crownfractures in which the fractured segment can berestored with composite resin or when rebonding ofthe fractures segment is possible.

808 Endodontics

With respect to the length of time pulp tissue can beexposed and still permit vital pulp therapy to be per-formed, studies by Heide28 and Cvek29 indicate that itmay be safe to proceed with shallow pulpotomies up to1 week post fracture. After that, it is probably question-able in mature, fully formed teeth, although in young,developing teeth with wide-open apices, it is worthattempting to save pulps even when they have beenexposed for more than a week. The goal is to promotecontinued root formation.

Follow-up and Prognosis. A number of studieshave evaluated the prognosis of traumatized anteriorteeth, including those with crown fractures.39–43 Theteeth need periodic evaluation, radiographically andclinically, to determine pulpal status. Discolorationassociated with the interphase between tooth structureand bonded resin material may indicate microleakage,and the restoration should be replaced to prevent bac-terial contamination of the exposure site. Acceptableresults of evaluation following pulpotomy should be allof the following42:

1. No clinical signs or symptoms2. No evidence of periradicular pathologic changes3. No evidence of resorption, either internal or external4. Evidence of continued root formation in developing

teeth

Evidence of root canal obliteration by calcified tissueis often taken as a sign of pulp degeneration. Lumenreduction can be seen years after trauma and treat-ment,44,45 but such calcification is not necessarily anindication of pulp necrosis.45 The decision to interveneendodontically in cases of apparent pulp space calcifi-cation should be based on evidence of pulp necrosisand not on pulp calcification.

If root canal treatment has been performed, eitherimmediately after the injury or subsequent to pulp cap-ping or pulpotomy, follow-up evaluation of healingshould be done, particularly if luxation of the toothoccurred, to monitor for possible root resorption.1

Primary Teeth. Crown fractures involving thepulp are not common in the primary dentition.46

When such injuries occur, pulpotomies or pulpec-tomies may be considered. Pulp capping is generallynot successful in primary teeth, and endodontic treat-ment is difficult owing to the tortuous and fine canalstructure. Patient management is a further complicat-ing factor in treating fractured primary teeth. Theresult of poor cooperation is often tooth extraction.47

Pulpotomy is indicated when the pulp is still healthyand pulpectomy when the pulp is not expected to


recover. The procedures are the same as describedabove for the permanent dentition, except that the rootcanal filling material should be a resorbable cementsuch as zinc oxide–eugenol. For additional details, seechapter 17.

Crown-Root Fractures

In these fractures, enamel, dentin, and cementum areinvolved. If the pulp is also involved, the case is consid-ered more complicated.

Description. Crown-root fractures in anteriorteeth are usually caused by direct trauma.48 This mayresult in a chisel-type fracture, with the apical extent ofthe fracture below the lingual gingiva (Figure 15-11).These fragments may be single or multiple, leaving thefragment or fragments loose and attached only by peri-odontal ligament fibers (Figure 15-12). The pulp mayalso be involved, depending on the depth of fractureinto the dentin, further complicating a difficult trau-matic injury.

In posterior teeth, the causes of crown-root fractureshave been attributed to indirect trauma includinglarge-size restorations, thermal cycling, high-speedinstrumentation, pin placement, and direct trauma,such as accidental blows to the face and jaws. The roleof restorative procedures is not well understood, par-ticularly in regard to occlusal restoration size andresultant fractures.49

As in anterior teeth, two types of crown-root frac-tures are recognized in posterior teeth: those with andthose without pulpal involvement.

The vertical fracture of endodontically treated teethis an additional type of crown-root fracture involvingboth anterior and posterior teeth (Figure 15-13). Mostappear to be caused by the endodontic treatment itselfor by subsequent inlay or dowel placement49 (seeChapters 13 and 19).

Incidence. Crown-root fractures per se are notgenerally recognized as a separate entity, and littleinformation is available about their frequency ofoccurrence. Andreasen and Andreasen reported a 5%incidence of total dental injuries.48 However, when oneincludes the so-called cracked tooth syndrome and ver-tical fractures of endodontically treated teeth (all arecaused by trauma in one form or another), the totalincidence may be higher. For additional information,see chapter 13.

Diagnosis. Crown-root fractures result in com-plaints of pain, particularly when the loose fragment orfragments are manipulated. The fragments are general-ly easy to move, and bleeding from the periodontal lig-ament or pulp often fills the fracture line. Because ofthe mobile parts, percussion is seldom useful in deter-mining apical periodontal involvement. However, thatmay be done later, after removal of the loose fragments.Unless the pulp is exposed, EPT should be performedon the injured and adjacent teeth.

Radiographs of anterior crown-root fractures areoften difficult to interpret. It is very important to takemore than one angulation to assess the extent of frac-tures. Angulations of films should include both addi-tional horizontal and vertical angulations.

Figure 15-11 A, Crown-root fracture of the “chisel type” extending below the alveolar crest palatally. B, Such teeth may be orthodonticallyextruded for restorative reasons.

BA

810 Endodontics

Figure 5-12 Crown-root fracture with pulp exposure. A, Note loose mesial crown fragments, which are attached by periodontal ligamentfibers. B, After anesthesia, loose fragments are removed and rubber dam applied. Note exposure of radicular pulp (arrow). C, The remain-der of coronal pulp tissue is amputated and the surface of pulp allowed to coagulate. Cotton pellet (CP) aids by controlling initial bleeding.D, After surface coagulation, the area is irrigated and calcium hydroxide placed directly over pulp tissue. It helps to prepare a shelf aroundthe pulp orifice to support the base and prevent the cement from being pushed into the underlying pulp tissue (arrows point to shelf indentin). E, After placement of base, acid-etched composite will be used for final restoration.

A B

C

D

E


Posterior crown-root fractures may be very difficultto diagnose because they are more inconspicuous. Theexamination and diagnosis of cracked tooth syndromeare discussed in chapters 6 and 7.

Treatment. There are several treatment optionsavailable for crown-root fractures, depending on theextent of the fracture.1 If the fragment can be reat-tached by bonding, and no pulp exposure has occurred,that is the most conservative and convenient approach.

If pulp exposure has resulted from the fracture (seeFigure 15-12), either a shallow pulpotomy procedure(if the tooth is still developing) or root canal treatment(fully developed teeth) must be done prior to anyrebonding or crown restoration.50

Crown-root fractures extending well below the alve-olar crest may require surgical repositioning of the tis-sues to expose the level of fracture. Long-term esthet-ic problems may, however, result from such surgicalprocedures.1

Extrusion—either surgical51 or orthodontic52—canalso be done to allow better restoration of the fracturedtooth. See Figures 15-14 and 15-15 for illustrations oforthodontic extrusion.

Prognosis and Follow-up. The quality of therestorative procedure is an important factor in deter-mining the long-term success of treating crown-rootfractures. Both the loss of significant tooth structureand often the difficulty in restoring normal crown con-tour contribute to a guarded prognosis.

If the pulp is not initially involved, its continuedvitality depends on one’s ability to protect it from con-tamination. If possible, the condition of the pulpshould be evaluated for a sufficient period of time todetect necrosis should it occur.

Primary Teeth. Fractures involving crowns androots of primary teeth occur infrequently, and whenthey do, extraction is indicated.48

Root Fractures

This type of fracture involves the roots only: cemen-tum, dentin, and pulp (Figure 15-16).

Incidence and Description. Intra-alveolar rootfractures do not occur frequently compared with otherdental injuries and account for probably less than 3%of all dental trauma. These fractures are generallytransverse to oblique and may be single or multiple,complete or incomplete.53 Incompletely formed rootsrarely fracture, but when they do, the prognosis is usu-ally very good.54

Diagnosis. Root fractures are not always horizon-tal; in fact, probably more often than not, the angula-tion of fractures is diagonal (Figure 15-17). This factprobably explains why root fractures are often missedradiographically. With the conventional 90-degree-angulation periradicular x-ray film, if the fracture isdiagonal, it is very likely that it will be missed. Onlywhen the x-ray beam can pass directly through thefracture line does it show on the radiograph. It is there-

Figure 15-13 Vertical root fracture of an endodontically treated tooth. A,Radiograph shows characteristic “drooping” lesion (arrows) around the root of a pre-molar with a very large diameter but short post. B, Photograph shows vertical frac-ture of the root (black arrow). B

A

fore imperative to take additional film angulationswhen root fracture is suspected.53

One additional film angulation (foreshortened or 45degrees) will, when combined with the standard 90-degree positioning, reveal most of the traumatic rootfractures.55

Treatment. If there is no mobility and the tooth issymptomless, the fracture is likely to be in the apicalone-third of the root, and no treatment is necessary

812 Endodontics

(Figure 15-18). If the coronal fragment is mobile, treat-ment is indicated. The initial treatment consists ofrepositioning the coronal segment (if it is displaced)and then stabilizing the tooth to allow healing of theperiodontal ligament supporting the coronal seg-ment53 (Figure 15-19).

Repositioning can be as simple as pushing the toothinto place with finger pressure, or orthodontic interven-tion may be required to move the displaced segment

Figure 15-14 Basic technique for root extrusion. A, Root fracture at or below crestal bone. B, Root canal therapy completed. C,Cementation of a post-hook. D, Occlusal view; horizontal wire is bent to cross midline of the tooth to be extruded. Wire is embedded withacid-etched composite on adjacent teeth. E, Elastic is attached to activate extrusion. F, When satisfactory extrusion has been completed, thetooth is stabilized until periodontal and bony repair are complete. G, Periodontal and bony repair completed. H, Permanent restoration. (Seealso Figure 15-15.)

CBA

D

E F

G H


Figure 15-15 A, Crown-root fracture of a right central incisor necessitating orthodontic extrusion owing to palatal extension of fracture.Note that the loose palatal segment (arrow) is still present. B, Adequate remaining tooth length allows use of the technique. C, One-visit rootcanal therapy performed after removal of loose palatal fragement. D and E, Extrusion hook cemented in prepared post space.

A

C

D E

B

814 Endodontics

Figure 15-15 (Continued) F, Horizontal wire attached to adjacent teeth at desired position by acid-etched composite. G, Activation elasticplaced over hook and wire. H, Two weeks later, the tooth has extruded the desired distance. I, It is now stabilized for 8 weeks by use of liga-ture wire.

F G

H I


Figure 15-15 (Continued) J, Note apical radiolucency (arrows) immediately following extrusion andK, recalcification after 8 weeks of stabilization. L, Palatal tissue shows good adaptation to crown(arrows). As a result of extrusion, gingival bevel could be placed on newly exposed tooth structure.

J K

L

816 Endodontics

Figure 15-16 A, Root fractures involve cementum, dentin, andpulp and may occur in any part of the root: apical, middle, or coro-nal thirds. B, Fractures may also be comminuted (arrows).

Figure 15-17 A, Graphic illustration showing two angulations(90 and 45 degrees) to better detect root fractures. B,Photograph showing a root fracture (arrow) that could not bedetected with a 90-degree angulation C, By changing the angu-lation to a more foreshortened view (approximately 45degrees). D, The fracture is easily demonstrated (arrow).

B C D

A

Figure 15-18 Root fracture (arrow) healed spontaneously. Thepatient was unaware of the fracture.

A B


Figure 15-19 Root fracture. A, Immediately after the accident. Note displacement of the coronal segment (arrows). B, The coro-nal segment has been repositioned and the splint has been attached to stabilize the fractured tooth. C, Radiograph taken justbefore removal of the splint. D, Control radiograph taken 1 year after removal of the splint. The tooth is comfortable and respondsto the electric pulp test within normal limits. There is no abnormal mobility or discoloration of the tooth. (Courtesy of Dr.Donald Peters.)

A B

C D

into proper alignment. Generally, if considerable timehas elapsed between the injury and the treatmentappointment, it is more difficult to reposition the coro-nal segment in line with the apical segment (“reducingthe fracture”).

Splinting is best accomplished by incorporating athin orthodontic wire into labially bonded compositeresin. The splint should allow for functional movementof the tooth to promote healing, and the length of sta-bilization time is 4 to 6 weeks.56

Following initial treatment by reduction and stabi-lization, repair by calcific and/or fibrous deposition isvery likely. About 80% of properly treated root frac-tures heal successfully. The prognosis is related to theamount of dislocation, stage of root development, andprobably whether treatment was done. Fracture loca-tion apparently matters less as long as it is not too closeto the alveolar crest.57

The amount of dislocation and the degree of mobil-ity of the coronal segment affect the prognosis becausethe more severe the dislocation (and therefore themobility), the less likely it is that fracture reduction canbe accomplished, and also the more likely it is that thepulp has been severely injured.58

The stage of root development matters in root frac-tures because, with other dental injuries, the moreimmature the tooth, the better the ability of the pulp torecover from trauma. The rich vascular supply to ayoung, immature tooth promotes repair.59

The conventional wisdom of dentists for years wasthat root fractures occurring in the coronal half had apoorer prognosis than those taking place more apically.In the important study by Zachrisson and Jacobsen onroot fracture outcome, it was surprising to see that loca-tion did not influence outcome.58 Apparently, then, if atooth can be stabilized long enough for repair to occur,the location of the fracture is immaterial. The onlyexception naturally would be fractures that occur soclose to the crest of the alveolar bone that the support ofthe tooth is compromised. Also, if communicationdevelops between gingival sulcus and the fracture site,the prognosis has to be considered poor.

Sequelae to root fractures may be divided into fourtypes, as proposed by Andreasen and Hjörting-Hansen60:

1. Healing with calcified tissue. Radiographically, thefracture line is discernible, but the fragments are inclose contact (see Figure 15-19, D).

2. Healing with interproximal connective tissue.Radiographically, the fragments appear separated bya narrow radiolucent line, and the fractured edgesappear rounded (Figure 15-20).

818 Endodontics

3. Healing with interproximal bone and connectivetissue. Radiographically, the fragments are separatedby a distinct bony bridge (Figure 15-21).

4. Interproximal inflammatory tissue without healing.Radiographically, a widening of the fracture lineand/or a developing radiolucency corresponding tothe fracture line become apparent (Figure 15-22).

The first three types are considered successfullyhealed injuries; they are asymptomatic, probablyrespond to electric vitality tests, and may, over time,show only signs of coronal discoloration (yellowing)owing to coronal calcification.57,58 Fractures that donot heal need additional endodontic treatment. Failingroot fractures have characteristic lesions that developadjacent to the fracture sites, not apically, as in mostteeth with necrotic pulps.60 Further, there is good rea-son to expect the apical segment of the root-fracturedtooth to contain vital, healthy pulp tissue, whereas thecoronal pulp is necrotic. The treatment options aretherefore many:1. Root canal therapy of both segments. This may be

indicated in fracture cases when the segments arenot separated, allowing passage of files and fillingmaterials from the coronal segment across the frac-ture site into the apical segment (Figure 15-23).

2. Root canal treatment of the coronal segment only(Figure 15-24). This is the current recommendation,particularly with the view that the apical segmentmay contain vital, healthy pulp tissue.54 A variationto this approach has been recommended by Cvek.61

He used an apexification procedure in the coronal

Figure 15-20 A, Root fracture in which healing resulted in con-nective tissue between the segments. B, Note that the segmentsappear to be separated by narrow radiolucent lines (arrows) and therounding effect of the fractured edges.

A B


segment, inducing a hard tissue barrier at the exit ofthe coronal root canal. Although there are no studiesat the present time reporting on the use of MTA inroot fractures, it would be reasonable to expect thatthis material could be used instead of calciumhydroxide in root fractures.9

3. The use of an intraradicular splint has been recom-mended by Weine et al.62 It is similar to the first pro-cedure described; both segments are treatedendodontically. Following root canal filling, a postspace is prepared in the canal to extend from thecoronal segment into the apical one, allowing place-ment of a rigid-type post (cobalt-chromium alloy[vitallium]) to stabilize the two root segments.

4. Root extrusion is a solution for teeth with root frac-tures at or near the alveolar crest.52 This treatmentplan must be evaluated carefully because the lengthof root left after the extrusion must be enough to

Figure 15-22 A, Root fracture resulting in interproximal inflam-matory tissure. B, Large periradicular lesion (small arrows) adja-cent to fracture line (white arrow).

Figures 15-21 A, Healing by interproximal bone. B, Root fracture (arrow) resulting in total separation of fragments. C, Midroot facture sta-bilized for 3 months. D, Note that after removing the splint, the incisal edges are even, yet a space is apparent between the segments. E, Eightmonths later, bone is now apparent between segments. F, The interproximal space has enlarged further 2 years after the accident. The toothis firm and functional. Note calcification of the pulp space. (Courtesy of Dr. Milton Siskin.)

A B C

D E F

A B

support a new crown. A reasonable guide is to con-sider a crown-root ratio of 1:1 to have adequatesupport. See Figures 15-14 and 15-15 for extrusiontechnique.

Follow-up and Prognosis. It is a commonly heldopinion that teeth with root fractures have a poor prog-nosis, particularly if the fracture is in the middle or coro-nal third. Whereas it may be true that the prognosis ispoor for longitudinal fractures, it appears unfounded fortransverse fractures56 (see Figure 15-19).

A slight discoloration of the crown is a frequentobservation in healed root-fractured teeth, usually seenas a yellowing effect with reduced transparency.63 It isassociated with pulp obliteration and occasionally a

820 Endodontics

loss of response to the EPT. Endodontic treatment isnot indicated unless other evidence, such as rootresorption or periradicular radiolucencies, indicatespulp necrosis. Usually, if the pulp space becomes oblit-erated, no radiolucencies are seen apically or associatedwith the fracture lines. Endodontic treatment thenbecomes a decision based on other factors pertinent toeach individual case.57

Teeth requiring endodontic treatment after rootfractures also have a good prognosis with proper treat-ment unless the fracture is so close to the alveolar ridgethat it communicates with the gingival crevice.57,58 Inthe latter case, removing the coronal fragment andextruding the root orthodontically may be the treat-ment of choice.52

Figure 15-23 Root fracture treated by root canal therapy of both apical and coronal fragments. A, Note the fistulous tract. B, Tract tracedwith a gutta-percha point to the root fracture (white arrow). Periodontal lesion associated with fracture is evident (dark arrows). C, Segmentsaligned properly so that instrumentation is possible. D, Sealer extruded into the interproximal area (arrows). E, Follow-up at 11 monthsshows resolution of the lesion with a small remaining area expected to heal.

A B

EDC


Long-term follow-up with radiographs and clinicaltests is indicated in root fractures cases, as with allother types of dental injury. It would appear that fewroot-fractured teeth need to be extracted. With propertreatment, even those with coronal-third involvementcan be expected to survive, although some will requireendodontic and possibly orthodontic intervention.

Primary Teeth. Root fractures are infrequent inprimary teeth. When they occur, however, the coronalfragment should be extracted. If the removal of the api-cal segment requires much manipulation, it may be leftin its socket. It will resorb during the growth and emer-

gence of the succedaneous tooth. Excessive manipula-tion may damage the permanent tooth bud.53

Luxation Injuries

This category of dental injuries includes impact traumathat ranges from minor crushing of the periodontal lig-ament and the neurovascular supply to the pulp tomore major trauma such as forceful and sometimestotal displacement of teeth (avulsion).

Injury to a tooth’s supporting structure seldomspares the pulp from trauma. Only in cases of minimaltrauma does the pulp have a good chance of recover-

Figure 15-24 A, Radiograph shows a central incisor with an apical root fracture and a crown fracture repaired with composite resin 7 yearsearlier. The pulp had not survived the original injury, and the patient had an apical abscess. Note the separated apical root segment.B, Radiograph taken 4 months after initial treatment: root canal cleaning and calcium hydroxide medications. C, The tooth immediately afterroot canal filling. Note that the apical lesion responded favorably to the initial endodontic therapy and the apical root fragment is notinvolved. D, Twelve months after filling the root canal, the radiograph shows good repair; the apical root fragment can be left in place.

A B

C D

ing. Otherwise, when a tooth is impacted by a blow, theforce is very likely to damage the vasculature enteringthe apical canal opening, with the result that the pulpalblood supply is compromised64,65 (see chapter 4).

Besides pulpal injuries, impact trauma may alsoaffect the tooth’s periodontal support. Loss of attach-ment, if not restored by subsequent repair, will result inpocket formation and reduction in tooth support. Thegoal in treatment of luxation injuries is to promoterecovery of both pulpal and periodontal health; realis-tically, except in young, immature teeth, pulpal recov-ery is not as likely to occur as periodontal repair.66

Incidence. Tooth luxation (not including avul-sion) is a frequent injury, comprising the largest groupof injuries in the classification of dental trauma, rang-ing from 30 to 44%.66 These figures are probably on thelow side since many instances of mild luxation, such asconcussion, go unreported. In severe injuries, luxationsmay go unnoticed in the face of more obvious injuries.It is important, though, to record findings indicatingluxations, even mild ones, because of the high rate ofsubsequent pulp necrosis, osteitis or apical periodonti-tis, and root resorption associated with such injuries.Following extrusion-luxation, Dumsha and Hovlandreported pulp necrosis in 51 of 52 teeth after a periodthat ranged from 4 weeks to 18 months.67

A frequently overlooked cause of luxation injuries,including avulsions, occurs during intubation in theoperating room. Damaged teeth were the most fre-quent anesthesia-related insurance claim during thetime period 1976 to 1983.68

Diagnosis. Luxated teeth that have been loosened orslightly displaced are sensitive to biting and chewing. Inconcussion, this may be the only symptom, and it isnoted by percussing the tooth. In more severe injuries,such as subluxation and extrusive luxation, signs andsymptoms in addition to percussion sensitivity may bepresent: sensitivity to pressure and palpation of the alve-olus, mobility, dislocation, and possibly bleeding fromthe periodontal ligament. Radiographs do not alwaysreveal the extent of injuries to the supporting structuresbut are important nonetheless; it is also important toinclude additional radiographic angulations. Dis-coloration of the crown may also be noted and, if presentshortly after the injury, is indicative of severe pulp dam-age. Lateral and intrusive luxations are usually firmly dis-placed and may not be sensitive to percussion.66

Electric pulp testing should be carried out andrecorded in cases of luxation, in spite of the fact that aninitial “no response” is common. The results of the EPTprovide the basis for later evaluation. It is generallyfound that teeth with an initial normal response but a

822 Endodontics

negative response later have developed either pulpnecrosis or calcification. However, without other indi-cations of pulp necrosis, endodontic interventionshould not be based solely on a negative response.

Treatment. Initial treatment can be as simple asdoing nothing while the patient avoids use of the tooth.In more serious luxations, treatment may range fromslight occlusal adjustment to repositioning (reduction)and splinting (stabilization) for 2 to 6 weeks. If symp-toms and other conditions (crown fracture with pulpexposure) indicate irreversible pulp involvement,endodontic treatment is indicated immediately afterinjury. Follow-up evaluation will determine possiblelater need for root canal therapy.69–73

Concussion

This is the mildest form of luxation injury, and it ischaracterized by sensitivity to percussion only. No dis-placement has taken place, and there is no mobility asa result of the injury. Concussion is probably present inmost cases of crown, root, and crown-root fractures.66

Treatment for concussion is symptomatic: allow thetooth to rest as much as possible to promote recoveryof trauma to periodontal ligament and apical vessels.Monitor pulpal status by EPT and watch clinically fortooth color changes and radiographically for evidenceof resorption. The prognosis is good.66

Subluxation

When a tooth, as a result of trauma, is sensitive to per-cussion and has increased mobility, it is classified assubluxated. Electric pulp test results may be either noresponse or positive; if they are the former, damage tothe apical neurovascular bundle is more severe, andpulpal recovery becomes questionable, except in devel-oping teeth.69–73

Treatment initially may be none, except to recom-mend minimal use, or it may be necessary to stabilizethe tooth for a short period of time (2 to 3 weeks) topromote periodontal ligament recovery and reductionin mobility1 (Figure 15-25).

Subluxated teeth need to be evaluated long enough tobe certain that the pulps have fully recovered. It may take2 or more years before one can make such a final deter-mination. Pulps that do not recover sensitivity to EPTshould be assumed to be necrotic even if they are asymp-tomatic. Definitive treatment for subluxated teeth oftenincludes root canal therapy for fully developed teeth.71

Extrusive Luxation

Displacement of a tooth axially in a coronal directionresults in a partial avulsion. The tooth is highly mobile


and is likely to be continually traumatized by contactwith opposing teeth, owing to the premature occlusalcondition, all of it contributing to patient discomfortand severe tooth mobility66 (Figure 15-26).

Immediate urgent care consists of repositioning thetooth, usually more easily accomplished than in lateralluxation, and stabilizing it by a functional splint for 4 to8 weeks (see Figure 15-25). The relatively long stabi-lization period is to allow realignment of the periodon-tal ligament fibers supporting the tooth. It is importantduring this period that gingivitis be prevented.Gingival inflammation will negate any attempt of thetissue to repair itself. During recovery, progress can bemonitored by periodontal probing. When reattach-ment has occurred, probing depth should be similar topretrauma depth.1,66

Definitive treatment for extrusive luxation is likelyto include root canal therapy,71 except in young, devel-oping teeth in which the pulps are more prone torecover.69 It is important to watch for signs of rootresorption if endodontic therapy, for any reason, is notincluded in the early treatment plan. Root canal thera-py should be performed if the pulpal condition at anytime is judged to be either irreversible pulpitis or pulpnecrosis. It should be done without delay once the deci-sion to do so has been made to reduce the chances ofinflammatory root resorption.1,67

Lateral Luxation

Traumatic injuries may result in displacement of a toothlabially, lingually, distally, or mesially (Figure 15-27).

Such displacement is called lateral luxation, and it isoften very painful, particularly when the displacementresults in the tooth being moved into a position of pre-mature occlusion. An example of such lateral luxation iswhen a maxillary incisor is pushed palatally. The crownmakes occlusal contact long before centric occlusion.The tooth is painful from the injury alone, and the addi-tional constant trauma of premature contact results insevere pain.

Initial, urgent care for lateral luxation cases includesrepositioning the tooth and stabilization if the tooth ismobile after being repositioned. Repositioning a later-ally luxated tooth may require pressure application atthe apical end of the root in the direction of the rootapex’s original location or by partially extracting thetooth with forceps prior to repositioning. The splint-ing, if needed, should be nonrigid and may need to bein place for 3 to 4 weeks, depending on how soon thesupporting tissues recover.1,66

Definitive treatment for laterally luxated teeth includesroot canal therapy (Figure 15-27, D), except in develop-ing teeth, which may revascularize.69,70 The tooth dis-placement has probably severed the blood vessels supply-ing the pulp, resulting in an infarct of the pulp owing tohypoxia. The end result is coagulation necrosis, which,even if asymptomatic, requires root canal therapy. If adecision to delay endodontic treatment is made, it isimperative to monitor the tooth radiographically for pos-sible external, inflammatory root resorption. The prog-nosis for lateral luxation is good if proper endodontictherapy is performed when indicated.66

Figure 15-25 Examples of two types of functional splints. A, Unfilled resin is bonded to small, etched labial areas. Avoid etching inter-proximally. B, A thin (0.3 mm) orthodontic wire can be bonded to small, etched labial areas with resin.

A B

Intrusive Luxation

A tooth may be pushed into its socket, resulting in avery firm, almost ankylosed tooth (Figure 15-28). Suchintrusive luxations require diverse treatment approach-es depending on the stage of tooth development: littleor no treatment for very immature teeth, aggressiveinitial treatment for more mature teeth.1,66

824 Endodontics

In cases of intrusive luxation of developing, imma-ture teeth, the theory behind not doing anything ini-tially is based on the expectation that a tooth with awide open apex has the potential to re-erupt sponta-neously and establish a normal occlusal alignmentwithin a few weeks or months74 (Figure 15-29).Monitor the progress of re-eruption, and if the tooth

Figure 15-26 A, Tooth extrusion is similar to luxation in that the tooth is displaced, but the direction is axial. It may be accompanied byfracture of the alveolus. B, Note outline of root socket at apex (arrow). C, Bleeding is frequently seen from the gingival sulcus (arrows).

B

C

A


Figure 15-27 A, Tooth luxation with loosening and displacement is often accompanied by fracture or comminution of the alveolar socket.B, Luxation displacement of left central and lateral incisor and canine (arrows). C, After repositioning. D, The incisor required root canaltherapy about 3 months later. Canine retained its pulp vitality. (Courtesy of Dr. Raleigh Cummings.)

A B

C D

does in fact erupt into the normal position, no othertreatment is needed. Radiographic control will proba-bly show some bizarre pulpal calcification, but, lackingother evidence of pulpal deterioration, root canal ther-apy is not likely to be indicated.

Fully developed teeth, however, and those in whichthe roots are close to being developed should be reposi-tioned either surgically or orthodontically or by a com-bination of both.1 If allowed to remain in an intrudedposition, the tooth is very likely to become ankylosed,and later attempts at extrusion will probably be unsuc-cessful. The pulp should be prophylactically extirpatedas soon as feasible, followed by completion of the rootcanal treatment after healing of the periodontal ligament

826 Endodontics

(Figure 15-30). The exception to endodontic treatmentis when spontaneous eruption takes place in young,developing teeth1,66 (see Figure 15-29).

Prognosis and Follow-up Evaluation. Comp-lications following luxation injuries are frequent. Pulpnecrosis occurs in over half of the cases of lateral luxa-tion, and even in subluxations, pulp death occurs in 12to 20% of cases.66 Extension of pulp necrosis to theperiradicular tissues may take some time. Often apicalperiodontitis is not detected for several years post trau-ma, emphasizing the absolute need for long-term follow-up.71

Other complications are crown discoloration andreduction of the pulp lumen by calcification (Figure

Figure 15-28 A, Graphic illustration of a tooth intruded into the alveolar bone. B, Clinical photograph of intruded incisor. Note bleedingfrom injured labial gingiva.

Figure 15-29 A, Intruded immature tooth (arrow). B, Six weeks later. Note re-eruption of the left central incisor, almost catching up withits contralateral mate.

BA

A B


15-31). A yellow discoloration is indicative of pulpspace calcification, whereas a gray color indicates pulpnecrosis. Lumen obliteration, as observed radiographi-cally, is a very common occurrence but does not alwaysindicate pulp necrosis and does not alone indicate theneed for endodontic therapy even if the pulp does notrespond to EPT, as so often happens.64–67,69,74

Resorption (external or internal) occurs in 5 to 15%of luxation injuries, usually within the first year andoften within the first 2 to 5 months66 (Figures 15-32and 15-33). The possibility of resorption shows theneed for follow-up. During the first year after trauma,evaluation should be done after 4 to 6 weeks and after6 months. After that, yearly recalls are indicated.71

Treatment for resorption is root canal therapy,which can arrest the resorptive process if it is inflam-matory external or internal resorption.66,75

If root formation is incomplete at the time of trau-ma, its continuation may be interrupted if the pulpdies. This presents serious treatment problems.Apexification procedures will provide an apical stop forroot canal filling (Figures 15-34 and 15-35), but the

Figure 15-30 Maxillary central incisors were intruded; the crowns fractured also. A, The intruded teeth were orthodontically extruded andthe pulps were extirpated, followed by placement of calcium hydroxide in the canals. B, Radiographs taken after extrusion was accomplishedand the root canals were filled. The entire procedure took place over a 2-year period. No evidence of ankylosis is present. (Courtesy of Dr.Arthur LeClaire.)

A B

Figure 15-31 Right central incisor had been intruded in an accidentwhen the patient was about 6 years old. The tooth re-erupted, andmany years later the tooth is functional, asymptomatic, and respondsto electric pulp testing, but shows dystrophic radicular calcification.

828 Endodontics

Figure 15-32 External inflammatory resorption. A, Accidentallyluxated tooth, radiograph taken 8 weeks after the incident. Noteresorption of both dental hard tissues as well as adjacent alveolarbone. B, Immediately after root canal therapy. C, Control radiographtaken 12 months later. Note repair of the alveolus and establishmentof a new periodontal ligament space. The root canal procedurearrested the resorptive process. (Courtsey of Dr. Romulo de Leon.)

Figure 15-33 A, Internal resorption with a history of trauma. B, Immediately following root canal therapy.

A B

C

A B


teeth are weak and prone to fractures (Figure 15-36).Cvek showed that, after 4 years, fractures ranged from77% of the most immature teeth to 28% of the mostfully developed teeth.75 Every effort should be made topromote revascularization of pulps in traumatized,developing teeth to allow continued root formation.

It is possible that a reason for the high incidence ofcervical root fractures in teeth that have undergone cal-cium hydroxide apexification—in addition to the thinroot walls of developing teeth—may be an adverseeffect of calcium hydroxide on dentin, in which thedentin becomes progressively more brittle as it contin-ues to be in contact with calcium hydroxide.76

A better approach to apexification may be one inwhich a combination procedure is done (see Figure15-36):

1. Use calcium hydroxide for a short period of time—about 2 weeks—to assist in disinfection of the rootcanal.77

2. Place MTA in the apical part of the canal to serve asan apical plug that promotes apical repair.78

3. After checking that the MTA has cured, complete theroot canal treatment with gutta-percha and a bond-ed resin restoration extending below the cervicallevel of the tooth to strengthen the root’s resistanceto fracture.79

Primary Teeth. Injury involving primary teethresults in damage to the supporting structures muchmore frequently than in crown or root fractures.80 Theinitial observation is often a grayish discoloration of thecrown, which may change to a yellow color, indicatingcalcification (Figure 15-37). This is in contrast to per-manent teeth, in which a grayish crown discolorationindicates pulp necrosis. In primary teeth, the most fre-quent sequela to trauma is pulp space obliteration bycalcification, although internal and external resorption,apical lesions, and discoloration can occur.81

Since the primary crown changes color in most trau-ma cases, treatment, whether endodontic or exodontic,should be done only in the presence of other clinical orradiographic signs of pulp necrosis. Electric pulp test-ing of primary teeth is not practical, so one has to relyon other information, such as periradicular osteitis.81

If periradicular lesions develop, either endodontic orexodontic treatment is indicated. Although periradicu-lar inflammation of short duration appears to have lit-tle or no effect on the succedaneous permanent tooth,lesions present for protracted periods of time do causedefects in the permanent successor82 (Figures 15-39and 15-40).

Figure 15-34 Graphic illustration of apexification procedure usingcalcium hydroxide to induce apical closure. A, Tooth with a necroticpulp and an open, divergent apex. B, The thin root canal walls dictatethat canal preparation be done very gently with minimal removal ofdentin. The canal must be irrigated frequently. C, After careful cleans-ing of the canal, it can be filled with calcium hydroxide (a) to the levelof vital tissue. Using a prepared calcium hydroxide paste deposited bya syringe and needle (b) combination facilitates the procedure. D, Theneedle is withdrawn as the material is deposited in the canal. E, Duringthe treatment phase, the canal is filled with calcium hydroxide (a), ontop of which is placed a cotton pellet (b), followed by a reinforced zincoxide–eugenol paste or an acid-etched bonded resin. F, The goal is toinduce an apical hard barrier (d).

A B

C D

E F

830 Endodontics

Figure 15-35 Induction of root-end closure with calciumhydroxide paste. A, Pulps of all four maxillary incisors havebeen devitalized by a traumatic accident. The apices arewide open. B, Seven months after filling with calciumhydroxide paste, the root apices have closed sufficiently toallow root canal filling. C, Root canals filled with gutta-per-cha. Total apical closure is shown by dense blunted fillings(arrow). (Courtesy of Dr. Alfred L. Frank.)

Figure 15-36 Fracture prone tooth. A, Owing to pulp necrosis in a developing tooth, apexification wasbegun with a good initial result; the apex was developing a hard tissue barrier. But the tooth is weak andprone to fracture cervically (arrow). B, The tooth did fracture as a result of a minor injury to the teeth.

A B


Because little or no hard tissue barrier is present api-cal to primary teeth, traumatic intrusion of a primarytooth affects the odontogenesis and the eruption of thepermanent tooth. On the other hand, the damage isusually minor, and the majority of intruded primaryteeth re-erupt within 6 months. Treatment is onlysymptomatic, but follow-up evaluation is important. Ifevidence of apical inflammation becomes apparent,endodontic treatment or extraction is indicated to pro-tect the permanent successor.82–84

The most common observation of intruded primaryteeth is a yellow crown discoloration, indicating pulpalcalcification. No treatment is indicated for such teethunless pulp necrosis and apical periodontitis occur81

(see Figure 15-38).

Tooth Avulsion

An avulsed tooth is completely displaced out of itssocket; this trauma has also been referred to as an exar-ticulation.85

Figure 15-37 The use of mineral trioxide aggre-gate (MTA) for apexification. A, A combination ofluxation injury and crown fractures led to pulpnecrosis in the central incisors. After pulp extirpa-tion, the canals were medicated with calciumhydroxide for 2 weeks, followed by placement ofMTA in the apical portion of the canals. B, After theMTA had cured, the coronal portions of the canalswere filled with bonded resin and the access cavitieswere restored with composite. C, Two years later, theradiograph shows good periradicular repair andevidence of apical hard tissue. (Courtesy of Dr.Mahmoud Torabinejad.)A

B C

Description and Incidence. Teeth can be avulsedin many trauma situations. Sports and automobileaccidents are the most frequent causes. The incidenceof avulsion is reported to be less than 3% of all dentalinjuries.85

Tooth avulsion is a true dental emergency sincetimely attention to replantation could save manyteeth.85 Unfortunately, avulsed teeth are usually lost atthe accident scene, and both accident victims and thoseattending them may neglect to consider the value offinding and saving the teeth. This may graduallychange as the public continues to become aware of thepossibilities that avulsed teeth can be saved.

Examination. The patient should be carefully exam-ined regardless of whether the tooth has been replantedbefore coming to the dental office. Radiographs and clin-ical examination are necessary to help detect possible

832 Endodontics

alveolar fractures. Such fractures of the tooth socket mayreduce the prognosis but are not always a contraindica-tion. Examine the tooth carefully for debris or contami-nation. Record the time of the avulsion. The length ofextra-alveolar time determines both treatment proce-dures and prognosis. If the tooth has been left dry for lessthan 1 hour or kept in milk for no more than 4 to 6 hours,the protocol for treatment is described as “immediate”replantation; more than 1 hour of dry time is “delayed”replantation.1,11,85

Treatment: Immediate Replantation. Treatmentsuccess for avulsed teeth can be directly related to theextra-alveolar time before replantation: the sooner anavulsed tooth is replanted, the better the prognosis.86

With that in mind, dentists and their staff should beprepared to advise parents and others who may call toreport a tooth avulsion (Table 15-2).

Figure 15-38 Luxation injury to primary tooth. A, After injury to the right primary central incisor, the crown showed discoloration, butthe tooth was otherwise asymptomatic. B, The radiograph shows no displacement of the tooth. C, Six months later, the discoloration is nolonger present, and D, the radiograph shows that the pulp has undergone calcific metamorphosis as a response to the trauma. (Courtesy ofDr. Mitsuhiro Tsukiboshi)

A C

DB


Often the person calling is not able to follow instruc-tions to replant the tooth. Rather than waste time try-ing to explain a procedure to someone who is not pre-pared to follow the steps described, it is often morepractical to urge that the patient and the tooth bebrought immediately to the dental office. The mannerin which the tooth is transported is important andneeds to be explained to the person who accompaniesthe patient.

The ideal way to transport the tooth is to have itreplaced in its socket, even if it will need to be reposi-tioned in the dentist’s office.86 Hank’s Balanced SaltSolution has been recommended as a transport medi-um to be kept in places where avulsion may occur.87

Milk is more readily available and can serve satisfacto-rily for several hours to maintain cell vitality.88,89 Theleast favorable medium is water; however, that is betterthan allowing the tooth to dry. If no milk is available,or while milk is being obtained, the tooth should bekept in the vestibule of the patient’s mouth (or saliva)if possible.1

When the patient arrives, place the avulsed tooth insaline while the examination and preparation for replan-tation take place. Saline will support the survival of peri-

odontal ligament cells on the tooth’s root surface andallow the time necessary to prepare for treatment.90

Replantation in the office (Figure 15-41) must bepreceded by a careful evaluation of the traumatizedalveolus and the avulsed tooth. Radiograph the alveolarsegment involved and any other oral area that appearsalso to have been injured. Look for evidence, both clin-ically and radiographically, of alveolar fracture. Inspect

Table 15-2 Guidelines for Replantation

Ideally, if an avulsed tooth can be replanted at the site ofinjury, the prognosis is better than waiting until the patient istransported to a treatment facility. The following advice can begiven over the telephone to someone able to assist the victim:

1. Rinse the tooth in cold running water. The purpose isto rinse off any obvious debris that may have collectedon the root surfaces.

2. Do not scrub the tooth. The less the root surface istouched, the less damage to fibers and cells. Suggestthat the person applying these first-aid measures han-dle the tooth by holding on to the crown of the toothand not the root.

3. Replace the tooth in the socket. Many individuals, evenparents, may be squeamish about this step. A relativelyeasy way out is for the first-aid person to place thetooth, root tip first, partly into the socket, then let thepatient bite down gently on a piece of cloth such as ahandkerchief to move the tooth back into its normal,or nearly normal, position.

4. Bring the patient to the dental office right away to complete the treatment of replantation.

Figure 15-39 Discolored primary teeth indicating pulp trauma. A,The left primary central and lateral incisors have been retained byankylosis, whereas the permanent right incisors have already erupt-ed. B, Another case; both primary central incisors have necroticpulps, evidenced by discoloration and labial swelling over apices(open arrows).

Figure 15-40 Injury to primary teeth led to defects in crowns ofsuccedaneous central incisors.

A

B

834 Endodontics

Figure 15-41 Replantation of avulsed tooth; the extra-alveolartime was less than 1 hour. A and B, The patient brought the toothin his mouth. In the office, the tooth was placed in saline while thealveolar socket was examined. C and D, The avulsed tooth wasreplanted and splinted; the lacerated gingiva labial to the adjacentlateral incisor was sutured. Two weeks later, the splint was removedand endodontic therapy initiated. E and F, One year later, the toothis functioning well, the tissues have healed, and, radiographically,the replantation looks satisfactory. (Courtesy of Dr. MitsuhiroTsukiboshi.)

A

C

E

B

D

F


the alveolar socket for foreign bodies and debris, takingcare not to scrape the bony walls. The blood clot in thesocket can be gently suctioned and the socket irrigatedwith saline. Check the avulsed tooth for debris on theroot; if such debris cannot be rinsed off with saline orwater, gently pick it off with cotton pliers. Whileinspecting the tooth, it can be held by the crown with apair of extraction forceps. This permits examination ofthe tooth without touching the root surface.

After examining the alveolus and the tooth, beginreplantation. Gently insert the tooth into the socket;anesthesia will probably not be necessary. The insertionshould be slow and gentle so that pressure is mini-mized. When the tooth is nearly in place, have thepatient complete the process by biting on a piece ofgauze. Even small children will be able to follow theinstruction to bite gently, and it allows them a measureof participation in the treatment.

The following steps in the replantation treatmentalso apply to situations in which the tooth may havebeen replanted before the patient’s arrival. Check it foralignment with respect to adjacent and opposing

teeth. It is most important that it not be in hyperoc-clusion. Such premature contact would delay or pre-vent recovery.85

Next, evaluate the need for stabilization. Splintingmay not be necessary if the tooth fits firmly in its sock-et. If there is mobility, however, it should be stabilizedwith a functional splint (see Figure 15-25). Use either athin orthodontic wire (0.3 mm) attached with acid-etched resin to the labial surfaces of the replanted andadjacent teeth or use only an unfilled resin bonded tosmall etched labial spots. In mixed dentition and casesof missing, nonreplaceable adjacent teeth, other typesof splints may be necessary.1,85,86

The splint should be left in place only long enoughfor the initial reattachment of periodontal ligamentfibers; in most cases, that can be expected to take placein 1 to 2 weeks, after which the splint should beremoved 1,85,86 (Figure 15-42).

Further support of the replantation procedure con-sists of initial antibiotic coverage, tetanus prevention,and root canal therapy. The latter is ideally performed10 to 14 days after replantation.

Figure 15-42 A, Replanted tooth splinted for 7 days. A normal periodontal ligament (PDL) is evident in this 4-month specimen. B,Replanted tooth splinted for 30 days. Replacement and inflammatory resorption covered the apical half of the tooth. b = bone; c = cemen-tum; d = dentin. Reproduced with permission from Nasjleti CE, Castelli, WA, Caffesse RG. Oral. Surg 1982; 53:557.

A B

Antibiotics should be administered from the time ofreplantation; prescribe a dosage regimen similar to thatrecommended for a mild to moderate dental infection.Coverage for 5 to 7 days should suffice.85,91

If the patient has not had a tetanus vaccination,referral to a hospital or physician is indicated. If thepatient has had a vaccination, but more than 5 yearshave passed since the vaccination or any subsequentbooster injections, a booster injection following thereplantation is necessary.

The optimal time for root canal therapy in a replant-ed avulsed tooth is about 10 to 14 days after replanta-tion.85,89,92 The only exception to the rule of root canaltherapy for avulsed teeth is when the tooth is still devel-oping and has a wide open apical foramen93–95 (Figure15-43). Such teeth have the potential for pulp revascu-larization. If the replanted tooth falls into this category,monitor its progress carefully with frequent, periodicradiographs. If the pulp does not revascularize, it willbecome necrotic and lead to the same postreplantationsequelae that can be expected from any replanted tooththat has not been treated endodontically: inflammato-ry resorption (Figure 15-44).

Calcium hydroxide has been recommended as anintracanal medication during root canal therapy.85,96,97

Based on current evidence,89,92,97–99 it appears reason-able to use calcium hydroxide for canal disinfection

836 Endodontics

(about 2 weeks), and in situations in which resorptionhas begun, use the calcium hydroxide until resorptionhas ceased. The completion of the root canal treatmentmust include a proper root canal filling and a protectivecoronal restoration.

Treatment: Delayed Replantation. The treatment forteeth with more than 1 hour of extra-alveolar time includesefforts to slow the inevitable replacement resorption:

1. Examine the avulsed tooth for debris. In contrast toavulsed teeth with less than 1 hour extra-alveolartime, those with more than 1 hour are not expectedto retain the vitality of periodontal ligament cellsand fibers. Therefore, it is best to remove pieces ofsoft tissue attached to the root surface. This needs tobe accomplished without overtly scraping the rootsurface.1,11,85

2. Perform root canal therapy with the tooth in vitro.This can often be best accomplished by holding thetooth by the crown and proceeding with theendodontic treatment through an apical approach.Cut off 2 to 3 mm of the root apex to expose the rootcanal, extirpate the content of the canal and pulpchamber, and then fill with gutta-percha and sealer.An advantage in doing root canal therapy this way,along with convenience, is that the crown of thetooth can be left intact.

Figure 15-43 An avulsed left central incisor in a 6-year-old boy was replanted immediately. A, When re-evaluated after 8 weeks, there wasstill response to electric pulp testing. B, One year after trauma, the tooth was in the normal position and had no discoloration but did notrespond to electric pulp testing. The root has continued to develop and the pulp appears to be calcifying. Also note hourglasserosion/resorption cervically (arrows). (Courtesy of Dr. Robert Bravin.)

A B


3. Soak the tooth in a 2.4% fluoride solution acidulat-ed at pH 5.5 for 20 minutes or more. The fluoridewill slow the resorptive process.1,85

4. Prepare the tooth socket by gently curetting theblood clot out of the alveolar socket and then irri-gate with saline.1,85

5. Rinse the tooth thoroughly in saline and then insertit into the socket and splint for 6 weeks.1,85

6. An additional procedure that is showing promisein reducing resportion is to fill the tooth socketwith Emdogain (Biora, Inc, Chicago, Illinois) priorto replantation.100

Because replanted teeth with more than 1 hour ofextra-alveolar time are expected to resorb and ankylose,it is probably reasonable to expect only a limited lengthof service from such teeth.101 However, if the resorptionis relatively slow, several years of service may result, andthis is probably reason enough for performing this rela-tively simple procedure. It must be noted, however, thatin young patients, such ankylosis can result in a lack ofalveolar ridge development, so when infraocclusionbecomes apparent in a growing child, it may be advisableto remove the crown in a process termed “decoronation”to allow proper ridge development.102

Figure 15-44 Replanted avulsed tooth in whichrevascularization did not occur. A, Radiograph of aleft central incisor taken 2 weeks after replantation.Note the open apex. B, Radiograph taken 4 monthslater shows aggressive inflammatory resorption. Inan effort to try to keep the tooth for some time, thepulp was extirpated, and calcium hydroxide wasplaced in the canal. C, Six months later, the radio-graph shows remarkable response to treatment—anindication of the result that could have been accom-plished if endodontic therapy had been initiatedmuch earlier.

A

B C

Avulsed Teeth with Open Apices. The only excep-tion to the rule that replanted teeth must be treatedendodontically is the situation in which a very imma-ture, developing tooth with a wide open apex has beenavulsed and replanted (see Figure 15-43). Such teethhave the potential for revascularization and thereforeshould be monitored after replantation to look forsigns of revascularization (ie, continued root forma-tion and absence of resorption and ankylosis).95,103,104

It has been recommended to soak the avulsed tooth ina solution of doxycycline (1 mg/20 mL saline) prior toreplantation.11,104

Primary Teeth. Most authors advise againstreplantation of primary teeth unless ideal conditionsexist to prevent trauma to the permanent succedaneoustooth.105

Prognosis and Follow-up Evaluation. Resorptionis the most frequent sequela to luxation injuries; threedifferent types of resorption have been identified: sur-face, inflammatory, and replacement (ankylotic)resorption106–108:

• Surface resorption: small superficial cavities incementum and outermost dentin. This type is not

838 Endodontics

visible on radiographs and is usually repaired by newcementum. It may be transitory or progressive. Theformer leads to repair, the latter to further resorption(see below). Surface resorption is usually detectableonly histologically and probably represents part ofthe process that takes place both during recovery andas a prelude to more severe resorption.107

• Inflammatory resorption: radiographically seen as abowl-shaped resorptive area of the root and associat-ed with adjacent bony radiolucencies. It involves bothtooth structure and adjacent bone. Radiographically,there is apparent tooth loss along with adjacent bonydestruction. This type of resorption is typical in theapical area involving any tooth with a necrotic pulp;replanted teeth that have not had root canal treatmentoften show these resorptive lesions laterally as well asapically. Root canal therapy can be expected to arrestinflammatory resorption that involves replantedteeth; the resorption can be prevented by judicioustiming of the root canal therapy. Optimally, that isabout 10 to 14 days post replantation1,11,85,86,106 (seeFigure 15-44).

• Replacement resorption: resorption of the root sur-face and its substitution by bone, resulting in anky-

Figure 15-45 A, Reattachment of a replanted tooth treated enzymatically with hydrochloric acid, hyaluronidase, and glutaraldehyde.B, Control tooth, untreated and replanted, with extensive inflammatory and replacement resorption. Reproduced with permission fromNevins AJ, La Porta RF, Borden BG, Lorenzo P. Oral Surg 1980; 50:277.

A B


losis (Figure 15-45). This is a frequent sequela toreplantation. As tooth structure is resorbed, it isreplaced with bone that fuses to the tooth structure,thereby producing ankylosis. Root canal therapy hasno effect on replacement resorption (Figure 15-46).Replacement resorption can be expected in replant-ed teeth in which the root surface elements havebecome necrotic, usually owing to the drying effectof too long extra-alveolar time. Teeth not replantedwithin 1 hour of avulsion can be expected to fall intothis category.106,107

Facial Skeletal Injuries

Fractures of the Alveolar Process and the Mandibleand Maxilla. These are closed fractures or comminu-tions (crushing or compression) that involve the socketwalls in the case of the alveolar process fractures and mayor may not involve the tooth sockets in fractures of thebody of the mandible or the maxilla109 (Figure 15-47).

It was common practice in the past to remove teethlocated in a jaw fracture line. Today, however, it is rec-ognized that removal of such teeth does not improvethe prognosis for the bone fracture. With the use ofantibiotics, fractures involving teeth can be treatedconservatively.109–114

Figure 15-46 Radiograph showing replacement resorption 5 yearsafter replantation of an avulsed tooth with more than 2 hours extra-alveolar time. Note infraocclusion owing to the ankylosis.

Figure 15-47 A, Alveolar fracture (arrows) and displacement of right canine treated by repositioning the tooth. B, A few weeks later symp-toms indicative of apical periodontitis developed, and root canal therapy was performed. (Courtesy of Dr. Eugene Kozel.)

BA

Examination and Diagnosis. Fist fights and bicycleand traffic accidents account for most cases of jaw frac-tures. The most frequent locations are in the mandible—the angles near the third molars and the canine areas.110

Teeth involved in the fracture lines should be pulp tested;a transitory negative response is common, and of theteeth not responding initially, about 25% can be expect-ed to recover.112 Locating the fracture and identifying theinvolved teeth are the basic considerations in the exami-nation of this group of injuries.

Treatment. Initial treatment consists of reductionof the fracture and stabilization by splinting for 3 to 4weeks.112–114 Analgesic and antibacterial supportivetreatment is needed. Stabilization must be carefullydone because persistent dislocations increase thechances for pulp necrosis in affected teeth. Stabilizationshould be carried out as soon as possible.112 The lengthof time between trauma and treatment adversely affectsthe prognosis of involved teeth.111 Unless concomitanttooth fractures occur, no treatment of the teeth is need-ed initially.

Prognosis and Follow-up. Although teethinvolved in jaw fractures need not be extracted andmay help stabilization, 25 to 40% develop pulp necro-sis and in time develop periradicular lesions.111,113 Forthat reason, follow-up evaluation is important andshould be done at 3-, 6-, and 12-month periods afterinitial treatment. Yearly examination for several yearsalerts one to pulp complications necessitating treat-ment intervention. Although it may not be mandatoryto treat all teeth not responding to the EPT, it should benoted that in one report, all five such teeth that wereopened were found to have necrotic pulps.111–113

840 Endodontics

Temporomandibular Joint

A blow to the mandible may result in injuries to thetemporomandibular joints. In young children, thecondylar necks are rather thin and can easily fracture,particularly if the blow causes a retrusive force on themandible115 (Figure 15-48).

Clinically, traumatized joints may be painful to pal-pation; in more severe injuries, mandibular functionmay be compromised, and the patient may have diffi-culty moving the lower jaw.116

Immediate care of temporomandibular joint injuryinvolves jaw stabilization and symptomatic treatmentof joint pain. Careful evaluation, both radiographicand clinical, must be made to determine what, if any,definitive treatment will be necessary. Fractures of thecondylar neck with displacement of the condylar headare usually treated by closed reduction in young chil-dren. The displaced condyle remodels well to a normalupright position.117 The main factors to rememberabout trauma involving the temporomandibular jointsare (1) to not overlook the possibility of such fractures,particularly in young children,115 and (2) that preven-tive measures—seatbelts and airbags in cars and faceand mouth protection in sports—can be very effectivein reducing injuries.2

REFERENCES

1. Andreasen JO, Andreasen FM, Bakland LK, Flores MT.Traumatic dental injuries—a manual. Copenhagen;Munksgaard; 1999.

2. Padilla R, Dorney B, Balikov S. Prevention of oral injuries. CanDent Assoc J 1996;24:30.

3. Andreasen JO, et al. Replantation of 400 avulsed permanentincisors. Endod Dent Traumatol 1995;11:51.

Figure 15-48 Panoramic film of an 8-year-old patient after a bicycle accident. In addition to maxillary anterior crown fractures, the lefttemporomandibular condyle also fractured.


4. Andreasen JO. 35 years of dental traumatology. Lecture to theInternational Association of Dental Traumatology,Melbourne, Australia, March 15, 1999.

5. Andreasen JO, Andreasen FM. Classification, etiology and epi-demiology of traumatic dental injuries. In: Andreasen JO,Andreasen FM, editors. Textbook and color atlas of trau-matic injuries to the teeth. 3rd ed. Copenhagen:Munksgaard; 1993. p. 151–77.

6. Huelke DF, Compton CP. Facial injuries in automobile crash-es. J Oral Maxillofac Surg 1993;41:241.

7. Kvittem B, et al. Incidence of orofacial injuries in high schoolsports. J Public Health Dent 1998;58:288.

8. Kaste LM, et al. Prevalence of incisors trauma in persons 6 to50 years of age: United States, 1988–1991. J Dent Res1996;75:696.

9. Boyd J. Child abuse: P.A.N.D.A. program designed to helpdental professionals diagnose and refer abuse victims. CanDent Assoc 1994; Update 6(8):8.

10. Speight N. Nonaccidental injury. In: Meadow R, editor. TheABC’s of child abuse. BMJ 1989.

11. International Association of Dental Traumatology. Guidelinesfor the evaluation and management of traumatic dentalinjuries. Dent Traumatol 2001;17:1, 49, 97, 145, 193.

12. Andreasen FM, Andreasen JO. Examination and diagnosis ofdental injuries. In: Andreasen JO, Andreasen FM, editors.Textbook and color atlas of traumatic injuries to the teeth.3rd ed. Copenhagen: Munksgaard; 1993. p. 196–215.

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