Dental Traumatology 2012; 28: 19–24; doi: 10.1111/j.1600-9657.2011.01058.

Pulp and periodontal tissue

repair - regeneration or tissue metaplasia
after dental trauma. A review
REVIEW ARTICLE
Jens O. Andreasen Abstract – Healing subsequent to dental trauma is known to be very complex, a
Resource Centre for Rare Oral Diseases, result explained by the variability of the types of dental trauma (six luxations,
Department of Oral and Maxillofacial Surgery, nine fracture types, and their combinations). On top of that, at least 16 different
Copenhagen University Hospital, Rigshospitalet, cellular systems get involved in more severe trauma types each of them with a
Copenhagen, Denmark different potential for healing with repair, i.e. (re-establishment of tissue
continuity without functional restitution) and regeneration (where the injured or
Correspondence to: Jens O. Andreasen, lost tissue is replaced with new tissue with identical tissue anatomy and function)
Resource Centre for Rare Oral Diseases, and finally metaplasia (where a new type of tissue replaces the injured). In this
Copenhagen University Hospital, study, a review is given of the impact of trauma to various dental tissues such as
Rigshospitalet, Copenhagen, Denmark
Tel.: (+45) 34 45 24 31
alveolar bone, periodontal ligament, cementum, Hertvigs epithelial root sheath,
Fax: (+45) 35 45 44 29 and the pulp.
e-mail: [email protected]
Accepted 4 August, 2011

The healing after traumatic dental injuries has long been or lost tissue is regained by new tissue which restores
known to be very complex and often unpredictable (1). structure and function, whereas repair or scar formation
This complexity relates primarily to the large variations is a biologic process whereby the continuity of the
in injury types, which may involve six luxations and nine disrupted or lost tissue is regained by new tissue which
fracture types each resulting in a unique injury to hard does not restore structure and function (4). The term
and soft tissue (1). When it is further considered that tissue metaplasia is used when tissue of one type (e.g.
fractures and luxations are often combined, i.e. 54 pulp) is replaced by another type (bone, cementum, and
(6 · 9) healing scenarios exist (2). These injuries affect PDL). In this analysis, the alveolar bone injuries and
the dental organ that consists of at least 19 cellular PDL injuries will be the first to be described followed by
systems, most with a different healing potential. pulp injuries.
The multitude of trauma scenarios combined with the In the pulp and periodontium tissue, a number of
many cell types involved may explain why so many specific cells, located in the pulp, PDL, and alveolar
variations in healing may occur such as repair- and bone, are found which each has a certain capacity of
infection-related root resorption, cervical invasive root healing (5).
resorption, loss of marginal bone support, and ankylosis- The type of healing is determined upon the stem cell
related resorption, all related to periodontal ligament capacity in the given location (Fig. 1). Furthermore, a
(PDL) healing events (1). In regard to the pulp, race between different tissue compartment cells whereby
pathological healing events may include pulp canal a damaged PDL area can be occupied by bone cells and a
obliteration (PCO), root canal resorption, (repair and pulp space may become invades by PDL cells, PDL, and
infection related), and tissue metamorphosis where PDL bone cells or bone cells alone. These facts complicate
structures such as bone PDL and cementum are found significantly the healing after trauma and surgery.
inside the pulp. Altogether, at least 13 deviations in
healing (1, 3) are present. The purpose of the present Alveolar bone
article is to present a survey of the experimental and
clinical studies which may to a certain extent explain this
Alveolar bone loss
marked variation in the healing of the dental structures
after trauma. In this aspect, the following types of The healing events after surgical removal of the labial
traumas will be described: tissue ischemia, tissue crushing, bone plate have shown that this structure will be
and tissue loss (1). In this study, the following healing completely reformed (6, 7). This is explained by the
terminology will be used: regeneration is used for a bone-inducing capacity of vital PDL residing on the root
biologic process whereby the continuity of the disrupted surface (11) (Fig. 2).

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20 Andreasen

Periodontal ligament ischemia or contusion

In several experiments, it has been found that this may

lead to repair-related resorption or resorption ankylosis
(10, 14, 15) (Fig. 4).

Periodontal ligament loss facing the cementum

In several experimental and clinical studies, it has been

shown that this leads to ankylosis (3, 6, 10, 14, 16).
However, a size factor exists; in animal experiments,
defects less than 4mm2; showed either complete healing
or a transient ankylosis site which was later resorbed and
repair-related root resorption developed in these sites
(14) (Fig. 5). In larger sites (i.e. exceeding 4 m2), a
permanent ankylosis site was formed (14) (Fig. 6).

Cementum

Cementum loss

This event is created in case of an osteotomy affecting the

Fig. 1. In a tooth with immature root formation four different root surface (20–24) (Fig. 7) or apicoectomy (17, 18)
stem cell populations have been isolated. 1: Apical papilla stem
(Fig. 8) and in relation to a root fracture (19). In these
cells; 2: Dental pulp stem cells; 3: Periodontal ligament stem
cells; and 4: Bone marrow stem cells. cases, new cementum will be found on the exposed
dentin (9, 17, 18) (Fig. 8). This process apparently starts
from existing cementoblasts next to the tissue loss (17,
18, 20, 24).
(a) (b)

Hertvig’s epithelial root sheath

Loss of Hertvig’s epithelial root sheath (HERS)

This event may occur during avulsion and extrusion where

a separation zone may occur at the level of the pulpal
papilla (1). If the tooth is not replanted the isolated apical
papilla plus, the HERS may continue its activity and form
a root tip (25–27). Under experimental conditions, it has
been found that partly removal of the HERS may lead to a
compromised root development and invasion of PDL and
bone into the pulp canal (28) (Fig. 9).

HERS and ischemia damage

Fig. 2. (a) Isolated removal of the labial bone plate. (b)
Regeneration of this structure. This event may occur because of marked inaccurate
reposition where the revascular process becomes delayed
whereby the HERS becomes avital. This leads to
invasion of bone, PDL and cementum in the pulp canal
Alveolar bone ischemia and crushing and lack of further root formation (28, 29) (Fig. 9).
This event has been examined in intrusion cases, and the
general feature is that the bone regeneration is good HERS and contusion damage
especially in children with immature root formation,
whereas in cases with mature root formation, transient This event may occur after lateral luxation, intrusion, and
or permanent loss of bone may occur (12, 13). avulsion with subsequent replantation (1, 12, 13). The
healing event appears to be similar to HERS ischemia.
Periodontal ligament
Pulp
Periodontal ligament loss facing the alveolar bone
Pulp loss
One study has examined the role of this structure and it
appears that the loss does not prevent regeneration of the This may occur as a therapeutic measure. Experiments in
PDL (9) (Fig. 3). monkeys have shown that in mature teeth a pulp

 2011 John Wiley & Sons A/S

 Pulp and periodontal tissue repair 21

(a) (b)

Fig. 3. (a) Isolated removal of the alveolar part of the periodontal ligament (PDL). (b) Healing of the entire PDL.

(a) (b)

Fig. 4. (a) Contusion or ischemia of the entire periodontal ligament. (b) This may lead to ankylosis.

(a) (b) (c) (d)

Fig. 5. (a) Isolated removal of the cemental part of the periodontal ligament. (b) This may lead to transient ankylosis (c and d).

revascularization process becomes arrested (8, 30, 31). In Such events lead to severe changes in the pulp chamber,
teeth with immature root formation, pulp revitalization ranging from pulp regeneration, pulp repair with accel-
will occur, although at a slower rate compared with a erated dentin formation (PCO) (1), or pulp metaplasia
situation where the ischemic pulp is preserved (32–34). where PDL ± bone invade the pulp and finally a sterile
or infected pulp necrosis may occur (1) (Fig. 10). The
revitalization process appear to be very dependent upon
Pulp ischemia
the size of the apical foramen, being very frequent with
This event happens in all tooth displacement injuries apical diameters above 1.0 mm and infrequent with
where the vascular supply is damaged or ruptured (1). diameters below 0.3 mm (35).

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22 Andreasen

(a) (b)

Fig. 6. (a) Larger injury to the cemental part of the periodontal ligament has taken place. (b) A permanent ankylosis is formed.

(a) (b)

Fig. 7. (a) Small osteotomy plus removal of periodontal ligament (PDL) and cementum. (b) Reformation of a functional PDL with
new cementum.

(a) (b) have shown that this event represents a high risk of
infected pulp necrosis as well as a risk of PCO or PDL
plus bone invasion. This addiction arrested root devel-
opment is a frequent finding (12, 13). All of these events
possibly relate to the damage or loss of HERS whereby
invasion of periodontal structures (cementum periodon-
tal ligament and bone) obtain a preference to invade the
pulp chamber (1).

Conclusion
This survey of the healing responses in the pulp and
periodontium after trauma strongly indicates that the
survival of the cell layer next to cementum appears to be
crucial for PDL healing including alveolar bone. The
Fig. 8. (a) Apicoectomy. (b) Reformation of a functional survival of HERS appears to be decisive for further root
periodontal ligament with new cementum. development. Finally, the presence of ischemic but intact
pulp tissue appears to be strongly related to survival or
regeneration of tertiary dentin. However, the latter will
only occur of the ischemic pulp tissue do not become
Pulp contusion damage
infected, and the apical foramen has a certain critical
This injury may occur subsequent to intrusion into the width allowing the revitalization of the ischemic pulp
bone of teeth with immature roots (12, 13). Statistics tissue.

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 Pulp and periodontal tissue repair 23

(a) (b)

Fig. 9. (a) Hertwigs epithelial root sheath is damaged. (b) Bone and periodontal ligament invasion may take place in the root canal.

10. Andreasen JO. Relationship between cell damage in the

periodontal ligament after replantation and subsequent devel-
opment of root resorption. A time-related study in monkeys.
Acta Odontol Scand 1981;39:15–25.
11. Lindskog S, Lengheden A, Blomlöf L. Successive removal of
periodontal tissues. Marginal healing without plaque control.
J Clin Periodontol 1993;20:14–9.
12. Andreasen JO, Bakland LK, Matras R, Andreasen FM.
Traumatic intrusion of permanent teeth. Part 2. A clinical
study of the effect of preinjury and injury factors, such as sex,
age, stage of root development, tooth location, and extent of
injury including number of intruded teeth on 140 intruded
permanent teeth. Dent Traumatol 2006;22:90–8.
13. Andreasen JO, Bakland LK, Matras R, Andreasen FM.
Traumatic intrusion of permanent teeth. Part 3. A clinical
study of the effect of treatment variables such as treatment
delay, method of repositioning, type of splint, length of
splinting and antibiotics on 140 teeth. Dent Traumatol
2006;22:99–111.
Fig. 10. Infected pulp necrosis. 14. Andreasen JO, Kristerson L. The effect of limited drying or
removal of the periodontal ligament. Periodontal healing after
replantation of mature permanent incisors in monkeys. Acta
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 2011 John Wiley & Sons A/S