2021 - Krastl - Endodontic Management of Traumatic Injuries To

Received: 21 October 2021
| Accepted: 2 December 2021
DOI: 10.1111/iej.13672
REVIEW
Present status and future directions: Endodontic

management of traumatic injuries to permanent teeth
Gabriel Krastl1 | Roland Weiger2 | Kurt Ebeleseder3 | Kerstin Galler4
1
Department of Conservative Dentistry Abstract
and Periodontology, Center of Dental
The prognosis of traumatized teeth depends largely on the fate of the pulp and its
Traumatology, University Hospital of
Würzburg, Würzburg, Germany treatment. This review aims to update the present status on the endodontic man-
2
Department of Periodontology, agement of traumatic injuries to permanent teeth and to identify relevant research
Endodontology and Cariology, Center areas that could contribute to an improvement in diagnosis and treatment of trauma-
of Dental Traumatology, University
Center for Dental Medicine UZB, tized permanent teeth. Future research should pay greater attention to (1) diagnostic
University of Basel, Basel, Switzerland methods to assess the perfusion of the pulp and enhance detection of tooth cracks
3
University Clinic of Dental Medicine and initial signs of root resorption; (2) improved materials for vital pulp treatment;
and Oral Health, Medical University
(3) studies focusing on type and duration of splinting after root fractures; (4) antire-
Graz, Graz, Austria
4
Department of Conservative Dentistry
sorptive intracanal medication in case of posttraumatic pulp necrosis and infection-
and Periodontology, University Hospital related resorption and (5) long-term data on the apical barrier technique compared
Erlangen, Friedrich-Alexander- to revitalization.
University Erlangen-Nürnberg (FAU),
Erlangen, Germany
KEYWORDS
Correspondence avulsion, dental trauma, diagnosis, endodontic management, tooth fracture, tooth injuries
Gabriel Krastl, Department
of Conservative Dentistry and
Periodontology, Center of Dental
Traumatology, University Hospital of
Würzburg, Pleicherwall 2, D-97070
Würzburg, Germany.
Email: [email protected]
I N T RO DU CT ION this review aims to update the present status on the end-
odontic management of traumatic dental injuries (TDIs)
A recent bibliometric analysis has revealed that dental in the permanent dentition and to identify relevant re-
traumatology remains an evolving field of research with search areas that could contribute to an improvement in
a large number of publications over the last two decades diagnosis and treatment of traumatized teeth.
(Liu et al., 2020).
The considerable number of articles in journals which
focus on endodontology underlines the important role of THE CONDITION OF THE
the pulp in the management of traumatized teeth. Despite TRAUMATIZED PULP: PRESENT
this high research activity, there is a lack of high-quality STATUS
well-designed studies in some areas.
In addition to the recently published comprehen- In general, an accurate diagnosis of the condition of the
sive review and the position statement of the European pulp is of utmost importance in order to make the cor-
Society of Endodontology (ESE, 2021; Krastl et al., 2021), rect treatment decision; however, none of the available
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2021 The Authors. International Endodontic Journal published by John Wiley & Sons Ltd on behalf of British Endodontic Society.
Int Endod J. 2022;55(Suppl. 4):1003–1019. wileyonlinelibrary.com/journal/iej | 1003

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1004 ENDODONTIC MANAGEMENT OF TRAUMATIC DENTAL INJURIES
diagnostic tests can clearly distinguish a treatable from All these factors have to be borne in mind when per-
a non-treatable pulpal condition (Mejare et al., 2012). forming sensibility testing of the pulp after dental trauma,
Particularly after TDIs, further limitations can complicate and obtaining the correct pulp diagnosis is only possible
the diagnosis. Patient compliance is required, which might through combining and assimilating findings from the pa-
not be granted due to young patient age or distress after tients’ history, analysis of the injury pattern, further diag-
the traumatic impact, leading to false results. Commonly nostics as well as radiographic assessment, which are all
used sensibility tests are based on thermal or electric stim- an integral part of the diagnostic process.
ulation. Thermal tests activate hydrodynamic movement Despite the limitations of conventional 2D radiography
of fluid within dentinal tubules, which excites the A-delta in visualizing three-dimensional anatomical structures,
fibres, whilst electric pulp tests result in a direct stimu- periapical (PA) radiographs combined with clinical exam-
lation of the A-delta fibres (Jafarzadeh & Abbott, 2010). ination remains the standard of care and should always
Both tests are physiologically dependent on a functional be considered during the initial evaluation of the patient
vascular supply. Therefore, reaction to sensibility testing (Bourguignon et al., 2020).
is used as an indirect indicator (surrogate) of a vital pulp. Cone beam computed tomography (CBCT) can provide
These limitations of conventional pulp testing make diag- valuable additional information but its use should always
nostics following trauma challenging, as temporary loss of be balanced against the potential risks (ESE, 2019a). On the
sensibility occurs frequently due to pulpal oedema after one hand, cases that appear straightforward on periapical
luxation injuries. In such cases, it may take a few to sev- radiographs might present a different and more complex
eral weeks before a response to sensibility testing returns situation when evaluated three-dimensionally (Cohenca &
(Bastos et al., 2014; Rock & Grundy, 1981; Skieller, 1960). Silberman, 2017). At the same time, it should be taken into
Thus, no reaction to sensibility testing after trauma does account, that particularly in children, the tissues are more
not necessarily indicate pulp necrosis; it rather indicates sensitive to the effects of ionizing radiation (Whitworth,
damage to the pulpal tissues with consequences regard- 2018) with children below the age of 10 years having a 3-
ing prognosis, as an intact vascular supply is responsible fold probability of radiation-induced stochastic effects com-
for pulp survival. Additional difficulties may occur after pared to those over 30 years of age (Horner et al., 2004).
repeated injuries, which can influence sensibility testing Thus, CBCTs should be considered in situations in which
and the healing capacity of the pulp. Furthermore, neu- further imaging is required to obtain an accurate diagno-
ral regeneration progresses at a slower rate compared sis and develop a correct treatment plan and where the
to vascular regeneration or may even fail to re-appear image is likely to change the management of the injury
(Kvinnsland et al., 1992; Schendel et al., 1990), which (Bourguignon et al., 2020). This applies particularly to cases
again conflicts with the nature of sensibility testing. of complex dento-alveolar trauma, such as root fractures
On the other hand, vitality tests (e.g. laser Doppler where a communication of the fracture lines with the oral
flowmetry, ultrasound Doppler flowmetry, pulse oximetry) cavity appears likely and to complications such as root re-
assess the blood supply of the pulp, thus offering a more sorptions (Dula et al., 2014; ESE, 2019a).
objective approach. Whereas vitality tests have been re-
ported to have superior diagnostic accuracy compared to
sensibility tests (Balevi, 2019; Ghouth et al., 2018; Lima THE CONDITION OF THE
et al., 2019), there might be a high level of bias (Ghouth TRAUMATIZED PULP: FUTURE
et al., 2019), and their complicated clinical application DIRECTIONS
makes the benefits of these tests questionable (Alghaithy
& Qualtrough, 2017). Another factor that has to be con- To overcome the limitations of current diagnostic proce-
sidered when assessing pulpal status after dental trauma dures, further advancement of current vitality tests (laser
is the stage of root development. Immature teeth are not Doppler flowmetry, ultrasound Doppler flowmetry, pulse
fully innervated and therefore associated with an increased oximetry) and development of new methods are highly
excitation threshold (Fulling & Andreasen, 1976), which desirable in order to provide a simple approach to reliably
may result in increased rates of false negative results, par- assess the perfusion of the pulp in routine clinical prac-
ticularly after electric pulp testing (Fuss et al., 1986; Rock tice. Furthermore, magnetic resonance imaging (MRI)
& Grundy, 1981). Colour changes may be concomitant ob- can be used to visualize perfusion of the pulp (Assaf et al.,
servations in traumatized teeth and may result from pulpal 2015). It remains to be answered under which conditions
haemorrhage (Andreasen, 1986). Pink colour changes that MRI might be a useful diagnostic tool in dental trauma-
occur shortly after the accident can be reversible. However, tology. Further, the traumatic displacement of the apex
if the crown of the tooth turns progressively grey, this may of the tooth might be used as a potential surrogate meas-
indicate pulp necrosis (Malmgren & Hubel, 2012). ure to pulp damage. It is conceivable that in the future,
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KRASTL et al. 1005
intraoral scans might be used on a regular basis during accident. If this is not feasible during the initial emergency
routine dental examinations (Suese, 2020). In case of luxa- treatment, placement of the restoration can be postponed
tion injuries in the permanent dentition, a post traumatic if the dentinal wound is sealed properly to prevent pulp in-
scan in combination with a CBCT can be used to accu- fection. Immediate dentine sealing can be carried out using
rately determine the amount of traumatic displacement of a dentine bonding agent and a layer of flowable compos-
the root tip compared to the stored data of the affected ite. Temporary dentine protection with calcium hydroxide
arch (Lee, 2021). Clinical studies might help to correlate cement or glass ionomer cement may be less effective but
direction and amount of displacement with survival of the can be applied if subsequent treatment takes place within
pulp, thus providing helpful treatment recommendations. the next few days (Krastl et al., 2020). Under optimal condi-
tions, the prognosis is favourable but periodic reevaluation
is recommended to determine the pulpal status.
E N D O DO NT IC M ANAG E ME N T
O F T R AU M AT ICALLY E XPOSE D
DE N T I NE : PR E SE N T STAT U S ENDODONTIC MANAGEMENT
OF TRAUMATIC ALLY EX POSED
After TDIs, dentine may be exposed following crown DENTINE: FUTURE DIRECTIO N S
fractures and crown- root fractures but even enamel
cracks extending into the dentine may represent poten- Whilst fibre-optic transillumination enables detection of
tial pathways for the invasion of microorganisms (Love, enamel cracks, it does not provide information on the ex-
1996). An infection of a healthy pulp via this pathway tension into dentine. Optical coherence tomography (OCT),
leading to necrosis is unlikely with a risk that has been a nondestructive imaging technique, first introduced more
reported to be less than 3.5% (Ravn, 1981a; Stalhane than two decades ago for imaging of dental tissues (Colston
& Hedegard, 1975). However, the risk of pulp necrosis et al., 1998) can add in-depth information and could be used
may increase in the presence of an undiagnosed concus- to assess crack progression (Imai et al., 2012; Shimada et al.,
sion or subluxation of the affected tooth due to a com- 2020). Thus, OCT may be a valuable diagnostic tool for
promised blood supply. cracks resulting from dental trauma if appropriate equip-
Adhesive sealing of enamel cracks has been reported ment for routine clinical use becomes available.
to be effective in laboratory studies in order to prevent
pulp infection (Love, 1996). However, there is no clinical
evidence whether sealing a crack increases the fracture ENDODONTIC MANAGEMENT O F
resistance of the crown or prevents pulp necrosis or disco- THE TRAUMATIC ALLY EX POSE D
louration of the crack lines. PULP: PRESENT STATUS
Most crown fractures expose dentine. In children, up
to 70 000 tubules per mm2 with a diameter of 2–5 µm and Most crown fractures occur in children and young pa-
communication with the pulp may be exposed (Garberoglio tients and usually involve teeth without preexisting pulpal
& Brannstrom, 1976; Ketterl, 1961). Due to an age-related damage from caries or previous dental trauma. Therefore,
smaller volume of peritubular dentine, a large percent- it can generally be assumed that the traumatically exposed
age of the total cross-sectional area in close proximity to pulps are healthy and capable of regeneration.
the pulp consists of lumina of dentinal tubules; therefore, Primate models studying the tissue reaction following
the fractured dentine is highly permeable (Mjor, 2009). experimental exposure of pulps to the oral environment
Defence mechanisms of the pulp such as the outward demonstrated the presence of inflammatory cells in the
flow of fluid through the dentinal tubules and the ability pulp at the exposure site. However, during the first hours
of the pulp to react to external stimuli with an immediate of exposure, the tissue alterations rather reflect the dam-
inflammatory response temporarily impede bacterial inva- age resulting from the mechanical trauma with negligible
sion and infection of the pulp tissue (Olsburgh et al., 2002). superficial inflammatory changes (Cox et al., 1982; Heide
Nevertheless, if major fractures are left without protection & Mjor, 1983). After 7 days of exposure, the inflammatory
of the dentine wound, pulp necrosis is likely to occur in response has been reported to be more pronounced but
more than 50% of the cases (Ravn, 1981b). The risk of pulp does not extend more than 2 mm into the pulpal tissue
necrosis is increased further in cases of concomitant lux- (Cvek et al., 1982). Thus, the conditions for vital pulp
ation injuries due to a compromised apical blood supply treatment (VPT) are favourable at least within the first
(Robertson et al., 2000). Therefore, a definitive adhesive days after trauma. Independent of the treatment strategy,
restoration (fragment reattachment or direct composite it is essential that the tooth is isolated with rubber dam
restoration) should be placed as soon as possible after the and disinfected prior to VPT (ESE, 2019b). Furthermore,
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the use of sterile instruments and magnification are highly contain zirconium oxide or tantalum oxide appear more
recommended throughout the entire procedure. colour-stable (Dettwiler et al., 2016; Haikal et al., 2020;
Direct pulp capping aims to maintain the vitality of the Lipski et al., 2018; Mozynska et al., 2017).
entire pulp after application of a biomaterial directly onto A large variety of bioactive materials are available on
the exposed tissue (ESE, 2019b). Animal studies suggest the market, all of them sharing calcium-silicate-chemistry
that direct pulp capping may be successful even if de- with desirable biological effects. However, the use of light-
layed for 24 h (Cox et al., 1982; Pitt Ford & Roberts, 1991). curing liners and cements with calcium hydroxide or MTA-
Nevertheless, direct pulp capping after trauma is usually additives as pulp capping agents cannot be recommended
recommended for small pulp exposures which are treated now due to the paucity of reliable data regarding biocom-
shortly after the injury (Cvek, 1978; Krastl & Weiger, patibility and due to potentially toxic effects of the mono-
2014). Thus, partial pulpotomy is preferable for the ma- mer components (Camilleri et al., 2014; Dammaschke
jority of cases, particularly if a large area of the pulp is ex- et al., 2019a; Hebling et al., 2009). Likewise, dentine ad-
posed and the treatment cannot be performed within the hesives and composite resins are not biocompatible and
first few hours after the injury (Dammaschke et al., 2019a; therefore cannot be recommended as pulp capping mate-
Krastl et al., 2020). rials (Costa et al., 2000; Dammaschke et al., 2019a).
Partial pulpotomy is preferably performed using a small After application of non-staining HCSC or a calcium
cylindrical diamond bur in a high-speed handpiece under hydroxide suspension onto the exposed pulp, the capping
continuous irrigation and involves removing approximately material must be covered with a thin layer of a hard-
2 mm of the coronal pulp. Similarly to direct capping, rins- setting material, to avoid unintentional removal during
ing the pulp wound with sodium hypochlorite (0.5%–5%) is the restorative procedures that follow. Subsequently, the
particularly recommended during partial pulpotomy to as- exposed dentine should be rinsed thoroughly and cleaned
sist haemostasis and disinfection (ESE, 2019b; Munir et al., with water to minimize the negative impact of disinfect-
2020). Cotton wool or sponge pellets soaked in sodium ing solutions on the adhesive bond. The definitive adhe-
hypochlorite can be applied with gentle pressure. If the re- sive restoration should ideally be applied during the same
maining pulp is reduced to a healthy level, bleeding is ex- visit. Partial pulpotomy can be performed during initial
pected to stop within 5 min. If haemostasis has not occurred trauma care. It can also be carried out secondary to emer-
within this time frame, the removal of the entire coronal gency pulp capping after a few days without compromis-
pulp (full pulpotomy), can be considered as the last measure ing success (Wang et al., 2017).
to maintain the vitality of the radicular pulp. The absence of A hard tissue bridge with histological evidence of tu-
any bleeding following pulp amputation is associated with bular dentine may form over the healed pulp tissue (Nair
a compromised blood supply to the pulp and is a negative et al., 2008). However, in most cases, bridge formation
predictor for the success of VPT. after pulp capping procedures is rather regarded a repair
Before starting the capping procedure, the operator process due to its unstructured mineralization and lack of
must ensure that there is no blood clot on top of the ex- native tubular morphology (Dammaschke et al., 2019b).
posed pulp. The selection of the capping material for In contrast to VPT of cariously exposed pulps where
direct pulp capping and partial pulpotomy primarily de- HCSCs clearly outperform calcium hydroxide in terms of
pends on its bioactive properties but should also take the clinical success (ESE, 2019b), in the treatment of traumat-
risk of crown discolouration into account. ically exposed pulps, the capping material (calcium hydrox-
Calcium hydroxide is still commonly used as a pulp ide vs. HCSC) does not seem to be a decisive factor (Bissinger
capping material and has been reported to have high et al., 2021; Dammaschke et al., 2019a). A retrospective
success rates (Dammaschke et al., 2019a) despite its me- study demonstrated a significantly higher success rate when
chanical instability and the dissolution of the material a new generation of HSCS was used instead of calcium hy-
over time (Bakland & Andreasen, 2012). Thus, calcium droxide, however the latter still achieved a clinical success
hydroxide is highly dependent on the protection of a high- rate of 93% (Rao et al., 2020). A randomized controlled trial
quality restoration to prevent bacterial invasion of the demonstrated a similar pulp survival rate in traumatized
pulp (Bakland, 2009). Hydraulic calcium silicate-based immature teeth treated with partial pulpotomy regardless
cements (HCSC) overcome the problem of mechanical of whether calcium hydroxide or a new generation of HSCS
instability, at the same time they offer excellent biologi- was used as a capping material (Yang et al., 2020).
cal properties. The drawback of some of these materials is Thus, calcium hydroxide can still be used but specific
their discolouration potential caused by the included radi- non-staining HCSC are the first choice (Abuelniel et al.,
opacifiers and by absorption of blood components due to 2020; Haikal et al., 2020; Parinyaprom et al., 2018).
porosities within the material (Krastl et al., 2013; Lenherr Survival of the pulp after complicated crown fractures
et al., 2012). Newer formulations of these materials that can be achieved in 43%–90% with direct pulp capping (Fuks
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KRASTL et al. 1007
et al., 1982; Hecova et al., 2010; Ravn, 1982; Wang et al., affected in this way. The condition of the pulp following
2017) and 86%–100% with partial pulpotomy (de Blanco, displacement of the coronal tooth fragment can only be
1996; Cvek, 1978, 1993; Fuks et al., 1987; Hecova et al., estimated at the first clinical examination and continuous
2010; Wang et al., 2017). Given the greater success rates monitoring is necessary to make a final diagnosis of the
of partial pulpotomy compared to direct pulp capping, the pulpal status.
indication for direct pulp capping can be questioned. Previous traumatic events and the age of the patient
Partial pulpotomy after trauma is associated with very have been suggested to impact pulp survival (Andreasen
high success rates particularly in immature teeth (90%– et al., 2004a, 2004b). The validity of any sensibility test is
100%) but also high success rates ranging from 70% to limited during the first weeks after the traumatic event.
100% in mature teeth (de Blanco, 1996; Cvek, 1978, 1993; An initially negative response is not a clear indicator that
Fuks et al., 1987; Hecova et al., 2010; Wang et al., 2017). the pulp will not recover. Pulp healing is more likely in
With increasing age of the patient, alterations in terms of immature teeth as well as in teeth with root fractures with
a reduced cell density and an increased amount of fibrous a positive pulp reaction at the time of first examination
tissue may reduce the pulp tissue's regenerative capacity following the accident (Andreasen & Kahler, 2015).
(Goodis et al., 2012; Murray et al., 2002). Nevertheless, A reddish discolouration of the crown may occur im-
vital pulp treatment after trauma should not be reserved mediately after the injury in some cases as a result of
for children and adolescents only but should be consid- diffusion of blood components into dentine. This disco-
ered for adults as well. However, particularly in teeth with louration may either remain or disappear (transient coro-
completed root formation, even minor luxation injuries nal discolouration; Heithersay & Kahler, 2013) and is not
may compromise the nutritional supply to the pulp, and necessarily a sign of pulp necrosis.
therefore substantially affect the success of vital pulp The various root resorption processes that may occur
treatment (Lauridsen et al., 2012a, 2012b, 2012c; Ravn, following root fracture are usually related to marked os-
1981b; Robertson et al., 2000). Teeth that have under- teoclastic activity during the healing process and do not
gone pulp preservation procedures should be periodically require endodontic treatment (Andreasen & Andreasen,
monitored to assess the treatment outcome (Jafarzadeh & 1988). External surface resorption may lead to a round-
Abbott, 2010). ing of the fracture edges and may be associated with a
widening of the fracture line during the initial phases
of fracture healing (Andreasen & Hjorting- Hansen,
E N D O DO NT IC M ANAG E ME N T OF 1967). Internal surface resorption has been described
T H E T R AU MAT ICALLY E XPOSED as a circular radiolucent area starting at the intersec-
P U L P : F UT U R E DIR ECT ION S tion of root canal and fracture line due to a rounding
of the fracture edges at the pulpal aspect of the frac-
Whilst the success rates achieved with VPT of traumatically ture (Andreasen & Andreasen, 1988). Internal tunnel-
exposed pulps hardly offer much room for improvement, ling resorption likewise begins at the fracture line but
both handling characteristics and aesthetic properties of burrows behind the predentin layer of the root canal
HCSCs may be improved further. Fast-setting and highly walls. Furthermore, partial to complete obliteration is
colour-stable HCSC materials can favourably influence a common finding on follow-up radiographs taken after
VPT of traumatically exposed pulps. some months, affecting almost three quarters of the
Even though observational and retrospective data sug- teeth with root fractures. In the majority of cases ei-
gest a similar distribution of success rates after partial pul- ther the apical fragment or both the apical and coronal
potomy irrespective of patient age, additional research is fragment are affected, but rarely the coronal fragment
needed to provide a reliable body of evidence on vital pulp alone (Andreasen & Andreasen, 1988). In almost 80% of
treatment in adults and elderly patients. treated teeth with intra-alveolar fractures (below the al-
veolar bone crest level), favourable healing with either
hard tissue fusion of the fragments (30%) or interpo-
E N D O DO NT IC M ANAG E ME N T sition of soft tissues (with or without bone formation)
FOL LOWI N G ROOT F R ACT U R E S: in-between the fragments (48%) has been demonstrated
P R E S E N T STAT U S (Andreasen et al., 2004a). Surprisingly, in intra-alveolar
cervical fractures, the chance of pulp healing is greater
Intra-alveolar root fractures of permanent teeth with vital compared to fractures located at the middle or apical
pulps result in an injury to the pulp tissues, primarily third of the root. This might be explained by the larger
compromising the neurovascular supply coronal to the fracture foramen (the diameter of the root canal where
fracture line. Maxillary anterior teeth are most often the fracture line is crossing) in the coronal fragment and
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the shorter distance needed to be revascularized in the subsequent surgical removal of the apical fragment or ex-
cervical region (Andreasen et al., 2004a). Nevertheless, traction of the whole tooth and subsequent replantation
even if healing occurs initially, the prognosis of teeth of the root canal-treated coronal part are possible treat-
with cervical root fractures is poor because the highly ment strategies.
mobile coronal fragment is prone to further traumatic Shaping and filling both the coronal and the apical root
displacement (Andreasen et al., 2012a). Orthodontic re- canal by penetrating the tissue present in the fracture is
tainers may stabilize the tooth and increase its longevity unreliable and cannot be recommended.
(Tobiska & Krastl, 2018) but clinical evidence is missing. The prognosis of teeth with intra-alveolar fractures fol-
However, if there is an initially undiagnosed communi- lowing root canal treatment is favourable. Tooth survival
cation of the fracture line to the oral environment via has been reported to average 72% (fracture mid-root) or
the gingival sulcus, extraction of the coronal fragment is 67% (fracture apical), respectively, within an observation
inevitable (Andreasen et al., 2012a). Preservation of the time of 8 years (Andreasen et al., 2012a). The overall sur-
root and subsequent restorative treatment may still be vival rate of teeth with root fractures including endodon-
possible following surgical extrusion (Kahnberg, 1996). tically treated teeth has been reported to approach 88%
Apart from the fracture location, the extent of disloca- when teeth with cervical fractures are excluded as these
tion of the coronal fragment (i.e. displacement in any teeth are often extracted due to an excessive mobility and
direction) and tooth mobility are positively associated a decreased resistance of the coronal fragment to a new
with the risk of later pulp necrosis (Andreasen et al., impact (Cvek et al., 2008). There is only scarce data on
2004a). pulp survival within the coronal fragment for concomitant
Clinical signs indicating a loss of pulp vitality ap- crown fractures with exposed pulp. Cvek et al. (2004) de-
pear within the first three to six months, in some cases scribed five teeth with root fractures whose pulps survived
even later. The lack of a response to pulp sensibility following partial pulpotomy. Endodontic therapies aiming
testing is not conclusive for pulp necrosis (Bourguignon at revascularization or revitalization of the diseased coro-
et al., 2020). Thus, at least two symptoms, such as re- nal pulp tissue have only been presented in a few cases so
current negative response to vitality or sensibility tests far (Saoud et al., 2016).
and a grey discolouration of the crown should be pres-
ent for a reliable clarification of the tentative diagnosis
(Jacobsen, 1980). Pulp necrosis followed by endodontic ENDODONTIC MANAGEMENT
infection of the coronal fragment and inflammatory FOLLOWING ROOT FRACTURE S :
changes between fragments was detected in 22% of FUTURE DIRECTIONS
cases (Andreasen et al., 2004a). In these cases, a lateral
lesion at the level of the fracture line is detected radio- Hard tissue fusion of the fragments is regarded as the
graphically as a result of an infection of the coronal root most favourable type of healing because the mobility of
canal system (Andreasen & Hjorting- Hansen, 1967). the coronal fragment is effectively reduced (Andreasen
This lesion can often be diagnosed within the first year et al., 2012b). However, there is no clear evidence on how
which underlines the necessity of regular follow-ups. In this pattern of healing is most likely to be achieved. With
immature teeth, arrested root development is a typical regard to the type of splint, current guidelines suggest a
sign of pulp deterioration. The pulp tissue apical to the flexible splint for teeth with root fractures (Bourguignon
root fracture most often remains unaffected and vital in et al., 2020) based on a retrospective study of 400 root-
nearly all cases (Cvek et al., 2008). By contrast, signs of fractured teeth, which reported the highest frequency of
early pulpal calcification can often be seen on follow-up favourable healing outcomes when Kevlar fibre splints
radiographs which may be interpreted as a reaction of a were used (Andreasen et al., 2004b). This type of splint
vital apical pulp to the injury. was classified as flexible. However, considering that the
Root canal treatment, if necessary, should be limited to used fibres were completely embedded in cured resin
the coronal segment and follow the common guidelines. after polymerization, the extent of flexibility achieved
Due to the large size of the canal at the fracture site in with this splint may be questionable. Laboratory stud-
the coronal fragment, ‘working length’ determination, ies have demonstrated that covering flexible splints with
cleaning and shaping as well as canal filling may be chal- flowable composite increased splint rigidity (Franz et al.,
lenging, and it is recommended to use suitable strategies, 2013). Thus, clear evidence is missing, whether splinting
similar to the treatment of immature teeth. In the rare of root-fractured teeth should strictly follow the principles
cases that present with a lesion around the apical frag- promoted for luxated teeth using highly flexible splints or
ment, a combined treatment approach with root canal if more favourable healing results can be achieved with
treatment of the coronal segment as outlined above and increased splint rigidity. Regarding the splinting time, a
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KRASTL et al. 1009
recent paper suggests that long-term splinting may favour surface (particularly severe intrusions), external infection-
hard tissue deposition but clear evidence supporting this related root resorption (EIR) may be an inevitable conse-
is missing (Isaksson et al., 2021). quence (Kenny et al., 2003).
Therefore, further studies focusing on type and dura- Thus, the endodontic management after luxation inju-
tion of splinting after root fractures are warranted. ries varies between two extremes. On the one hand, root
canal treatment should not be initiated if preservation of
the pulp is a realistic scenario and revascularization of a
E N D O DO NT IC M ANAG E ME N T damaged pulp is likely to occur. On the other hand, an early
FOL LOWI N G LU XAT ION IN JU RIES: endodontic intervention is crucial in cases of high risk of
P R E S E N T STAT U S developing EIR. This applies particularly for severe intru-
sions. At advanced stages of root formation, repositioning
Through mechanical trauma following luxation injuries, of the intruded teeth is usually necessary to obtain access to
the pulp can be subjected to tension, compression or sepa- the root canal. Whilst there is no clear evidence whether the
ration at the apical constriction. The main parameters repositioning strategy (immediate surgical repositioning or
influencing pulp survival are the type and severity of the orthodontic repositioning) has an influence on the survival
luxation injury as well as the width of the apical foramen. of intruded teeth (Andreasen & Vestergaard- Pedersen,
Pulp repair may occur in immature teeth, with a re- 1985; Costa et al., 2017), from an endodontic perspective,
turn of sensibility within weeks to months (Andreasen, a repositioning method which allows early adequate root
1970, 1989; Andreasen & Vestergaard- Pedersen, 1985; canal treatment is preferable. In the absence of root canal
Andreasen et al., 1986). Several radiographic signs indi- infection, the severely damaged root surface may still be
cate pulpal healing. Continued root development and prone to resorption; however, replacement resorption will
pulp canal obliteration (PCO) indicate the reestablish- emerge instead of EIR. It is beyond the scope of this review
ment of the vascular supply of the pulp (Andreasen et al., to go into further details on the management of teeth with
1987; Bastos & Cortes, 2018; McCabe & Dummer, 2012). replacement resorption and ankylosis.
Transient apical breakdown is a rare finding (4.2%) in During the follow-up visits, a number of signs indi-
which a transient apical radiolucency initially occurs and cate infected pulp necrosis; however, due to the isch-
resolves within months to years, partially together with a aemic mechanism of pulp necrosis in luxation injuries,
gradually vanishing grey discolouration (Andreasen et al., most patients do not have pain or swelling. Tenderness
1986). Additional crown fractures with exposed dentinal to percussion is found only in teeth with acute periapi-
tubules are a negative co-factor in the healing of a trauma- cal inflammation. The presence of two of the three main
tized pulp (Lauridsen et al., 2012a, 2012b, 2012c). Dentinal symptoms (discolouration, negative sensibility, increasing
fluid from a healthy pulp flows out of the open tubules at periapical radiolucency) justifies endodontic intervention
the fracture site. However, if the blood circulation is re- (Andreasen & Andreasen, 2007; Jacobsen, 1980). Further
duced or lost, necrotic tissue dissolution generates nega- clinical signs may include a fistula/sinus tract, mucosal
tive osmotic pressure inside the pulp chamber resulting swelling, formation of an abscess or persistent mobility.
in an inflow of saliva (and bacteria) into the tubules In immature teeth, arrest of root development indicates
(Andreasen, 1995; Stenvik et al., 1972). Thus, the necrotic (infected) pulp necrosis. Rapid EIR mainly occurs after in-
pulp tissue becomes infected and healing is impossible. trusion and is a rare finding in the other types of luxation
The younger the patient, the larger the diameter of the injuries (Andreasen & Vestergaard-Pedersen, 1985).
dentinal tubules which means the pulp is more prone to Last but not least, regular follow-ups are needed to
infection. Other sources of infection are open dentine tu- ensure the current pulpal diagnosis was made correctly,
bules in the cervical region or an infected blood clot in the especially in cases with PCO and/or negative sensibility.
socket (Cvek et al., 1990b). Apart from their undoubted Follow-ups, including clinical and radiographic ex-
benefits, fixed splints have to be seen as plaque accumu- amination are recommended at least 2, 4, 6–8 weeks, 3,
lators. Therefore, similar to orthodontic treatment, appro- 6 months, 1 year after trauma and annually for 5 years
priate oral hygiene instructions should be given including post trauma.
the recommendation of an antiseptic mouth rinse. In doubt, shorter intervals should be chosen
In teeth with fully formed roots and severe traumatic (Bourguignon et al., 2020).
displacement of the tooth from its original position, pulp If root canal treatment is indicated, the treatment of
necrosis, followed by root canal infection and apical peri- immature teeth with non-vital pulps remains challenging.
odontitis is a common finding (Humphreys et al., 2003). Mechanical removal of root dentine from the thin root
Additionally, in cases with considerable traumatic me- canal walls during instrumentation should be limited to
chanical damage to the cementoblast layer on the root a minimum. Instead, the focus lies on copious irrigation
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using sodium hypochlorite to remove necrotic pulp tissue threats of teeth affected by severe luxation injuries, particu-
and disinfect the root canal (Trope, 2006). Irrigant activa- larly intrusions. Therefore, the development of pharmaceuti-
tion improves the cleansing effect and is therefore highly cal treatment strategies, either by internal application in the
recommended (Caputa et al., 2019; Swimberghe et al., root canal or by external application and treatment of the
2019). Apexification procedures with long-term calcium root surface is desirable. From an endodontic perspective,
hydroxide dressing in teeth at early stages of root forma- alternative anti-resorptive intracanal medicaments which
tion have a high risk of cervical root fracture (Cvek, 1992) might help to promote periodontal healing should be inves-
and should therefore be avoided. Both the apical barrier tigated in clinical studies (see also: Endodontic management
technique with HCSC and revitalization are currently rec- following avulsion: future directions).
ommended procedures. The apical barrier technique has
high success rates in terms of periapical healing ranging
between 81% and 96% (Bonte et al., 2015; Bücher et al., ENDODONTIC MANAGEMENT
2016; Mente et al., 2009; Moore et al., 2011; Pace et al., FOLLOWING AV ULSION: PRESE N T
2014; Simon et al., 2007; Witherspoon et al., 2008) but STATUS
only a few studies report long-term data after 8 to 10 years
(Pace et al., 2014; Ree & Schwartz, 2017). Avulsion of a tooth inevitably leads to necrosis of the dis-
The success rates after revitalization are comparable to rupted pulp. Replantation is the treatment of choice for all
the apical plug technique but long-term data is missing permanent teeth. In mature teeth (with closed root apex),
for this protocol (Kahler et al., 2017). Currently, adverse revascularization cannot occur after replantation. Instead,
events such as discolouration or the necessity to change regardless of whether the crown is intact or not, bacteria
the treatment option may be more likely after revitaliza- contaminating the root surface or the intra-alveolar blood
tion, but further root maturation may occur, even though clot will enter the necrotic pulp tissue (Cvek et al., 1990a)
the results regarding root lengthening and thickening are and infection of the pulp space is believed to be established
variable and not predictable (Kahler et al., 2017). as early as 2–3 weeks after replantation (Tronstad, 1988).
Another concern is that a potential increase of root There is consensus that in mature teeth, early root canal
thickness is usually limited to apical and mid-root areas, treatment is mandatory and should be initiated within
but not the cervical area, which is the region most sus- the first 2 weeks postreplantation in order to prevent EIR
ceptible to root fracture. The treatment modality appears (Fouad et al., 2020). Calcium hydroxide or an antibiotic-
to be beneficial especially in teeth at earlier stages of root corticosteroid paste can be used as intracanal medication.
development (Kim et al., 2018). Based on the assumption that calcium hydroxide may
impair initial periodontal healing due to diffusion of hy-
droxyl ions through dentinal tubules to the root surface
E N D O DO NT IC M ANAG E ME N T (Lengheden, 1994; Lengheden & Jansson, 1995), it has been
FOL LOWI N G LU XAT ION IN JU RIES: recommended to schedule the initiation of root canal treat-
F UT U RE D I RECT ION S ment to 7–10 days after replantation (Andersson et al., 2012)
in order to await the initial healing processes on the one
In cases of pulp necrosis following luxation injuries, hand, but to initiate treatment before pulp space infection
further clinical research comparing the apical barrier is established on the other hand. However, the diffusion of
technique with revitalization procedures is advocated to calcium hydroxide through the dentinal tubules is limited
generate evidence on which treatment approach can pro- by the buffering capacity of dentine and the presence of in-
vide the best long-term success. tact root cementum (Nerwich et al., 1993) and therefore, a
Since the presence of cells of the apical papilla and clinically significant change in the pH on the root surface
of Hertwig's root sheath influences tissue ingrowth and might not occur (Fuss et al., 1996). In any case, EIR can be
healing, damage to these structures might jeopardize prevented reliably if root canal treatment is initiated within
revitalization. 2 weeks postreplantation (Fouad et al., 2020). Depending
Thus, the influence of the type and the severity of lux- on the severity of periodontal damage caused during ex-
ation injuries on the outcome of revitalization procedures traoral storage, either periodontal healing or tooth anky-
should be evaluated in clinical studies in order to provide losis can be expected (Kenny et al., 2003; Lauridsen et al.,
clear recommendations for revitalization after different 2019). To increase the survival of teeth and achieve peri-
traumatic scenarios. odontal healing following replantation, immediate place-
Whilst pulp necrosis can be treated with one of the above- ment of alternative intracanal medicaments containing an
mentioned approaches, there is no reliable method of treating antibiotic-corticosteroid paste, such as Ledermix (Riemser)
ankylosis-related root resorption which is one of the major or Odontopaste (Australian Dental Manufacturing) have
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KRASTL et al. 1011
been proposed (Trope, 2011). After experimental avulsion missing (Tsilingaridis et al., 2015). Systemic treatment with
and replantation in animal trauma models, this treatment doxycycline failed to prevent or eliminate the contamination
approach was reported to promote favourable periodon- of the necrotic pulp tissue with microorganisms and there-
tal healing and reduce root resorption (Bryson et al., 2002; fore had no effect on the frequency of pulp revascularization
Wong & Sae-Lim, 2002). In a randomized controlled trial, (Cvek et al., 1990b). Nevertheless, the prescription of sys-
a higher proportion of replanted teeth had periodontal temic doxycycline may be justified to promote periodontal
healing if treated with Ledermix (8/12 teeth) compared to healing in avulsed teeth according to the current guidelines
calcium hydroxide (6/15 teeth). However, there was no sig- (Fouad et al., 2020; Hinckfuss & Messer, 2009).
nificant difference between the medicaments with p = .17. In general, after replantation of immature teeth, the
Ankylosis developed in the failing cases (Day et al., 2012). risk of EIR should be balanced against the chance of re-
In contrast to calcium hydroxide, Ledermix may be vascularization (Fouad et al., 2020). Thus, frequent follow-
placed immediately or shortly following replantation ups are mandatory for early detection of pulp necrosis and
(Andersson et al., 2012). Its main preventive mechanism EIR if revascularization is attempted but fails.
against root resorption does not rely on an anti-bacterial
effect, but on the direct inhibition of odontoclasts by de-
taching the resorbing cells from the root surface (Pierce ENDODONTIC MANAGEMENT
et al., 1988b). Although both the steroid-(triamcinolone FOLLOWING AV ULSION: FUTU RE
acetonide) and the tetracycline (demeclocycline hydro- DIRECTIONS
chloride) component in Ledermix have antiresorptive
properties, a similar effect was demonstrated when triam- The main goal in the treatment of avulsed teeth is peri-
cinolone was used alone after delayed replantation of teeth odontal healing which is mainly influenced by the stor-
(Chen et al., 2008). Thus, Odontopaste (Australian Dental age conditions before replantation. Whilst the benefit of
Manufacturing), which uses clindamycin as a substitute for systemic and topical medicaments is very limited, the
the stain-inducing tetracycline component, but shares the greatest potential may still be the application of suitable
same steroid component, is regarded as a reasonable non- medicaments in the root canal to maintain a therapeutic
staining alternative to Ledermix (Dettwiler et al., 2016). level of anti-clastic medicaments to the periradicular area
In teeth with wide-open apices, the treatment approach to promote periodontal healing. Future research should
is directed towards the re-establishment of a blood supply aim to confirm the favourable data from animal studies in
as these teeth may have the potential to revascularize and clinical studies with a sufficient number of patients.
continue their root development (Trope, 2011). However, In replanted teeth with open apices, natural revascu-
natural revascularization should only be considered as an larization is regarded as the most favourable outcome,
option, if the individual rescue chain (storage conditions of but there is scarce evidence on how this goal can be best
the avulsed tooth) suggests that there is a reasonable chance achieved. Topical treatment of the root surface with dox-
of periodontal healing (Trope, 2011). In a dog model, it has ycycline or minocycline before replantation has been re-
been demonstrated that revascularization of the pulp in reported to significantly increase the frequency of complete
planted immature teeth mainly occurs by ingrowth of newly pulp revascularization in animal studies by decreasing the
formed blood vessels, which was visualized by microangiog- frequency of microorganisms in the pulpal lumen (Cvek
raphy in the entire pulp 30 days post replantation in most et al., 1990a; Ritter et al., 2004). However, in a retrospec-
cases (Skoglund et al., 1978). The revascularization process tive case–control study with a small number of patients,
is influenced by the size of the apical foramen, particularly this effect could not be proven (Tsilingaridis et al., 2015).
by the length of the root, and can only occur in the absence Therefore, more clinical evidence on this topic is neces-
of bacteria (Andreasen et al., 1995a). The longer the root, sary. An additional approach to render the necrotic pulp
the greater is the distance to be revascularized and there- free of bacteria might include retrograde infiltration of the
fore the greater the chance of infection and the risk of EIR pulp with antibiotics before replantation.
(Andreasen et al., 1995a). The likelihood of natural revas-
cularization may exceed 40% under ideal conditions with
an apical foramen greater than 2.75 mm and a pulp length ENDODONTIC MANAGEMENT IN
less than 17 mm but may drop below 10% in immature roots C ASES OF EX TERNAL INFECTI O N -
with a distance to be revascularized of more than 19.5 mm RELATED RESORPTION (EIR):
(Andreasen et al., 1995a). Topical treatment of the root sur- PRESENT STATUS
face with doxycycline before replantation may be performed
to increase the likelihood of natural revascularization (Cvek Infection-related root resorptions (also referred to as in-
et al., 1990a) even though evidence from clinical studies is flammatory root resorptions) pose the biggest threat for
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teeth with severe luxation injuries (mainly avulsion and the root canal system is crucial and involves thorough
intrusion). They are initiated by a combination of severe canal debridement and irrigation with sodium hypo-
damage to the protective cementum layer on the root sur- chlorite. Activation of the irrigant promotes the removal
face and pulp space infection which is facilitated by the of pulp tissue remnants and hard tissue debris (Caputa
missing (avulsion) or considerably damaged (intrusion) et al., 2019; Swimberghe et al., 2019) and is therefore
neurovascular supply of the pulp tissue. Even if the crown highly recommended. Smear layer removal with chela-
is intact, bacteria may enter a necrotic pulp through ex- tors such as EDTA is beneficial to facilitate the diffu-
posed dentinal tubules or enamel-dentine cracks as early sion of intracanal medicaments through dentine to the
as 2–3 weeks after trauma (Andreasen, 1981; Tronstad, external root surface (Heithersay, 2007; Tronstad et al.,
1988). Once the pulpal infection is established, external 1981). The standard approach for root canal medication
root resorption is maintained by microorganisms and is placement of a calcium hydroxide dressing. It has
their toxins, which enter the inflammatory process in the been demonstrated that the diffusion of calcium hydrox-
PDL via open dentinal tubules after loss of the barrier ide through the dentinal tubules significantly increased
function of the root cementum (Trope, 2002). the pH in resorption areas, where cementum was not
Apart from the lack of response to pulp tests, teeth with present (Tronstad et al., 1981). Thus, besides the anti-
EIR usually do not have any clinical signs of disease and bacterial and endotoxin-neutralizing effect in the root
therefore, EIR is most often diagnosed only radiograph- canal, calcium hydroxide has the potential to favour-
ically. Affected teeth are characterized by bowl-shaped ably influence the local environment at the resorption
radiolucencies along the root surface and corresponding sites through inactivation of acids and collagenases
defects in the adjacent alveolar bone. Numerous stud- which are released from the clastic cells. Furthermore,
ies have reported the limitations of 2D radiography and root surface repair might be promoted through stimu-
demonstrated that CBCT is more accurate in detecting lation of alkaline phosphatases by the alkaline pH at
EIR particularly in its early stages (Patel et al., 2015). the resorption sites (Tronstad, 1988). However, evidence
Nonetheless, a CBCT examination cannot be recom- supporting this widespread assumption is missing. An
mended for routine monitoring of teeth at risk for root animal study demonstrated that long-term intracanal
resorption, particularly in children, whose tissues are medication with calcium hydroxide for 3 months was
especially sensitive to the effects of ionizing radiation more effective than short-term application for 1 week
(Whitworth, 2018). After being asymptomatic for the first for the treatment of established EIR (Trope et al., 1995).
weeks, teeth with EIR may at later stages present with in- Clinically, high success rates in terms of healing or ar-
creased mobility, dull percussion sound, sensitivity to per- rest of the resorption, have been demonstrated following
cussion or with a sinus tract at later stages. medication with calcium hydroxide from 3 to 54 months
In teeth with closed apices at risk of root resorption due (mean value for immature teeth was 24 months and for
to severe luxation injuries, EIR can be reliably prevented mature teeth 11 months) (Cvek, 1992). However, there
by timely initiation of root canal treatment within the first is no consensus on whether long-term calcium hydrox-
2 weeks after trauma. Unfortunately, due to inadequate ide dressing up to the point when there is radiographic
endodontic management, EIR is a frequently encoun- evidence of resorption control is needed in cases of
tered sequel in clinical practice (Andreasen et al., 1995b). established EIR (Patel et al., 2016; Whitworth, 2018).
Moreover, in teeth with open apices, a treatment approach The recommendations for the duration of calcium hy-
intended to induce natural revascularization and promote droxide medication vary between 4 weeks (Darcey &
further root formation is usually adopted. If revascular- Qualtrough, 2013) and several months (Trope, 2002).
ization fails in these cases, EIR can cause complete root An alternative approach for treating established EIR in-
destruction within a few months (Tronstad, 1988; Trope, volves the use of antibiotic-corticosteroid combinations
2002). Therefore, early detection of EIR is crucial because such as Ledermix (Riemser) or Odontopaste (Australian
tooth preservation is unpredictable if large parts of the Dental Manufacturing) for eliminating the inflamma-
root are already affected. tory reaction in the periodontal membrane (Heithersay,
In teeth at high risk of EIR, the first follow-up ra- 2007; Pierce & Lindskog, 1987). Likewise, an animal
diographs should be performed 2, 4 and 6 weeks after study suggested the intracanal use of calcitonin as an
trauma to identify the first radiologic signs (small radio- adjunct in the treatment of EIR (Pierce et al., 1988a)
lucencies along the external root surface of the dentine but clinical studies are missing. A few case reports have
and adjacent bone), which may be already visible at these used regenerative endodontic procedures for treating
time points (Patel et al., 2016). Standardization of these teeth with EIR (Chaniotis, 2015; Lu et al., 2020; Santiago
radiographs facilitates the early identification of EIR. To et al., 2015; Saoud et al., 2016; Tzanetakis, 2018; Yoshpe
arrest EIR, the elimination of the microorganisms from et al., 2020); however, there is insufficient evidence to
|
KRASTL et al. 1013
support this approach for routine clinical practice in has been suggested that intrapulpal haemorrhage and
such cases. localized compression resulting from a blow might lead
After successful arrest of EIR, depending on the degree to death of odontoblasts and damage of the resorption-
of trauma-induced PDL damage, periodontal healing may resistant non-mineralized predentin layer in the affected
occur, or the process may develop into ankylosis. area of the root canal (Whitworth, 2018). As a result, the
mineralized tissue becomes exposed to pulpal cells with
resorbing potential. The resorptive process is stimulated
E N D O DO NT IC M ANAG E ME N T IN by the presence of bacteria in the necrotic pulp coronal
C A S E S O F E XT E R NAL IN FECT IO N- to the resorption, whilst the pulp tissue at and apical to
REL AT E D RE SOR PT ION (E IR ): the resorption area is vital. Thus, the process can be inter-
F UT U RE D I RECT ION S preted as a defensive reaction of sound apical pulp tissue
against its necrotic and infected coronal part. The multi-
The prognosis of teeth with EIR mainly depends on their nuclear clastic cells in the highly vascularized resorption
early detection so that root canal treatment can be initiated tissue induce a symmetric expansion of the pulp canal
as early as possible. However, small initial resorptive lesions which can result in perforation of the root at later stages
are difficult to detect on 2-dimensional radiographic im- (Haapasalo & Endal, 2006). The resorptive process will
ages, particularly on the buccal and palatal aspect of the only cease if pulp necrosis of the apical pulp cuts of the
root. Artificial intelligence (AI) is increasingly being used nutritional supply for the resorbing cells or if endodontic
to improve diagnosis in different fields of clinical dentistry intervention is initiated.
(Reyes et al., 2021). AI algorithms may be a valuable tool A special form of internal resorption is internal re-
for monitoring traumatized teeth at high risk of developing placement resorption. In such cases, the resorptive process
EIR and for detection of initial radiologic signs of EIR. within the root is accompanied by a reparative process that
Even though EIR is primarily a radiologic diagno- results in the deposition of metaplastic bone/cementum-
sis, a clinical diagnostic approach seems conceivable. like tissues in the resorption area (Patel et al., 2010).
Two recent studies identified IL-1α in the gingival sul- In general, root canal treatment is regarded as the
cus fluid of affected teeth as a potential biomarker for treatment of choice for internal resorption. Before starting
EIR (Gregorczyk- Maga et al., 2019, 2021). Further re- treatment, it must be ensured that the diagnosis is correct,
search is needed to evaluate the clinical usefulness of since external invasive cervical resorption is often misdi-
biomarker-based diagnostic tests for this specific type of agnosed as internal resorption (Patel & Ford, 2007). It is
root resorption. beyond the scope of this review to address this different
Whilst the treatment of teeth with infection-related re- type of resorption which has extensively been discussed in
sorption primarily relies on disinfection of the root canal, various articles (ESE, 2018).
there is no evidence whether the use of antiresorptive cor- Root canal treatment of teeth with internal resorption
ticosteroid or hormone dressings in the root canal (possi- should follow the conventional guidelines. Copious irri-
bly followed by calcium hydroxide) increase the likelihood gation using sodium hypochlorite and activation of the
of successful periodontal healing compared to the use of irrigant is crucial to remove any necrotic pulp tissue and
calcium hydroxide alone. Therefore, clinical studies eval- ensure adequate disinfection of the internal resorption
uating this effect are needed. Likewise, clinical evidence is defect.
needed to assess whether regenerative endodontic proce- Complete filling of the resorptive defect is best
dures can be recommended for the treatment of teeth with achieved with thermoplastic gutta-percha techniques or
infection-related resorption. with HCSCs in case of perforation (Patel et al., 2010).
E N D O DO NT IC M ANAG E ME N T IN ENDODONTIC MANAGEMENT IN

C A S E S O F I N T E R NAL R E SOR PTION CASES OF INTERNAL RESORPTIO N
( I R ) : P RE S E N T STAT U S (IR): FUTURE DIRECTIONS
Internal progressive root resorption (‘internal ganuloma’) The drawback of the conventional endodontic treatment
is a rare endodontic complication after trauma but other approach for cases of internal resorption is that the
initiating factors such as invasive crown preparation of weakened root remains susceptible to spontaneous
teeth with vital pulps or chronic pulpal inflammation are fracture after root canal filling. To address this problem,
also discussed (Haapasalo & Endal, 2006; Trope et al., a promising regenerative treatment alternative has been
2016). Although the aetiology is not fully understood, it suggested (Ebeleseder & Kqiku, 2015). The authors have
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Dental Traumatology guidelines for the management of trau-

impressively shown that disinfection and application of matic dental injuries: 22. Avulsion of permanent teeth. Dental
calcium hydroxide in the space coronal to the resorptive Traumatology, 28, 88–96.
site, turns the granuloma into a calcifying hard tissue which Andreasen, F.M. (1986) Transient apical breakdown and its relation
is able to restore the defect in the root. Thus, not only the to color and sensibility changes after luxation injuries to teeth.
weak root is strengthened but also the tooth is preserved Endodontics and Dental Traumatology, 2, 9–19.
with a vital pulp. Recent case reports with a comparable Andreasen, F.M. (1989) Pulpal healing after luxation injuries and
approach confirmed the feasibility of this treatment even root fracture in the permanent dentition. Endodontics and
Dental Traumatology, 5, 111–131.
for severe cases where preoperative CBCTs demonstrated
Andreasen, F.M. (1995) Pulpal healing after tooth luxation and root
perforation of the root surface (Arnold, 2021; Kaval et al., fractures in the permanent dentition. Thesis. Kopenhagen:
2018) but valid clinical data on the success rates is needed. Kopenhagen.
Andreasen, F.M. & Andreasen, J.O. (1988) Resorption and mineral-
ization processes following root fracture of permanent incisors.
CON C LUS I ON Endodontics and Dental Traumatology, 4, 202–214.
Andreasen, F.M. & Andreasen, J.O. (2007) Luxation injuries of per-
manent teeth general findings. In: Andreasen, J.O., Andreasen,
The pulp plays a central role in the management of trau-
F.M. & Andersson, L. (Eds.) Textbok & Colour atlas of traumatic
matized teeth and significantly influences their longevity,
injuries to the teeth, 4th edition. Oxford: Blackwell-Munksgaard,
particularly in severe cases. There is a need for future re- pp. 372–403.
search to pay greater attention to (1) diagnostic methods Andreasen, F.M. & Kahler, B. (2015) Pulpal response after acute den-
to assess the perfusion of the pulp and enhance detection tal injury in the permanent dentition: clinical implications-a re-
of tooth cracks and initial signs of root resorption; (2) view. Journal of Endodontics, 41, 299–308.
improved materials for vital pulp treatment; (3) studies Andreasen, F.M. & Vestergaard-Pedersen, B. (1985) Prognosis of
focusing on type and duration of splinting after root frac- luxated permanent teeth–the development of pulp necrosis.
Endodontics and Dental Traumatology, 1, 207–220.
tures; (4) antiresorptive intracanal medication in case of
Andreasen, F.M., Zhijie, Y. & Thomsen, B.L. (1986) Relationship be-
posttraumatic pulp necrosis and infection-related resorp- tween pulp dimensions and development of pulp necrosis after
tion and (5) long-term data on the apical barrier technique luxation injuries in the permanent dentition. Endodontics and
compared to revitalization. Dental Traumatology, 2, 90–98.
Andreasen, F.M., Zhijie, Y., Thomsen, B.L. & Andersen, P.K.
ACKNOWLEDGMENTS (1987) Occurrence of pulp canal obliteration after luxation
Open access funding enabled and organized by injuries in the permanent dentition. Endodontics and Dental
ProjektDEAL. Traumatology, 3, 103–115.
Andreasen, J.O. (1970) Luxation of permanent teeth due to trauma.
A clinical and radiographic follow-up study of 189 injured
CONFLICT OF INTEREST teeth. Scandinavian Journal of Dental Research, 78, 273–286.
The authors have stated explicitly that there are no con- Andreasen, J.O. (1981) Relationship between surface and inflamma-
flicts of interest in connection with this article. tory resorption and changes in the pulp after replantation of per-
manent incisors in monkeys. Journal of Endodontics, 7, 294–301.
AUTHOR CONTRIBUTION Andreasen, J.O., Ahrensburg, S.S. & Tsilingaridis, G. (2012a) Root
Gabriel Krastl: Conceptualization, writing, review and fractures: the influence of type of healing and location of frac-
ture on tooth survival rates -an analysis of 492 cases. Dental
editing (lead). Roland Weiger: writing, review and ed-
Traumatology, 28, 404–409.
iting. Kurt Ebeleseder: writing, review and editing.
Andreasen, J.O., Ahrensburg, S.S. & Tsilingaridis, G. (2012b) Tooth mo-
Kerstin Galler: writing, review and editing. bility changes subsequent to root fractures: a longitudinal clinical
study of 44 permanent teeth. Dental Traumatology, 28, 410–414.
ORCID Andreasen, J.O., Andreasen, F.M., Mejare, I. & Cvek, M. (2004a)
Gabriel Krastl https://orcid.org/0000-0002-9402-8121 Healing of 400 intra-alveolar root fractures. 1. Effect of pre-
injury and injury factors such as sex, age, stage of root develop-
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Received: 21 October 2021

| Accepted: 2 December 2021

Present status and future directions: Endodontic

Gabriel Krastl1 | Roland Weiger2 | Kurt Ebeleseder3 | Kerstin Galler4

Int Endod J. 2022;55(Suppl. 4):1003–1019. wileyonlinelibrary.com/journal/iej | 1003

E N D O DO NT IC M ANAG E ME N T IN ENDODONTIC MANAGEMENT IN

Dental Traumatology guidelines for the management of trau-

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2021 - Krastl - Endodontic Management of Traumatic Injuries To

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2021 - Krastl - Endodontic Management of Traumatic Injuries To

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2021 - Krastl - Endodontic Management of Traumatic Injuries To

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Received: 21 October 2021

| Accepted: 2 December 2021

Present status and future directions: Endodontic

Gabriel Krastl1 | Roland Weiger2 | Kurt Ebeleseder3 | Kerstin Galler4

Int Endod J. 2022;55(Suppl. 4):1003–1019. ﻿ wileyonlinelibrary.com/journal/iej | 1003

E N D O DO NT IC M ANAG E ME N T IN ENDODONTIC MANAGEMENT IN

Dental Traumatology guidelines for the management of trau-

You might also like

Int Endod J. 2022;55(Suppl. 4):1003–1019. wileyonlinelibrary.com/journal/iej | 1003