DOI: 10.1111/ipd.

12082

Healing complications of traumatized permanent teeth in

pediatric patients: a longitudinal study
THAIS R. C. SOARES1, RONIR R. LUIZ2, PATRICIA A. RISSO3 & LUCIANNE C. MAIA4
1
Department of Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de
Janeiro, Brazil, 2Institute of Public Health Studies, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, 3Department
of Dental Clinic, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, and 4Department of
Pediatric Dentistry and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

International Journal of Paediatric Dentistry 2014; 24:

380386
Background. Traumatic dental injuries (TDI) can

affect soft and hard dental tissues and supporting

structures in different ways and severity.
Aim. This study describes the complications associated with health in traumatized permanent teeth
(TPT) over a 12-month period and assesses the
relationships between TDI, involved tissues, and
root development (RD).
Design. The study enrolled 294 patients with
548 TPT. Data were collected on the TDI, RD,
and the healing complication (HC) and when
they were examined (03, 06, and 12 months).
Frequencies are described and analyzed using the
chi-squared test, relative risk (RR), and Mantel
Haenszel analysis (P 0.05).

Introduction

Traumatic dental injuries (TDI) involve different types of injuries, which depend on the
strength and the axis of impact. They can
affect the soft and hard dental tissues and
supporting structures in different ways and
severity1. A TDI can result in tooth loss
and extensive bone loss, with possible esthetic
deformity or occlusal interference15. The complexity of dental trauma is further increased by
the possibility of combining different injuries
that can lead to different healing complications
(HCs)1,36.
Healing complications depend on factors
such as the type of affected tissue, root develCorrespondence to:
Lucianne C. Maia, Disciplina de Odontopediatria da FOUFRJ, Caixa Postal: 68066 Cidade Universit
aria CCS,
CEP.: 21941-971 - Rio de Janeiro RJ Brazil. E-mail:
rorefa@terra.com.br

380

Results. Healing complications were present in

201 (36.68%) teeth and were more frequently
diagnosed 3 months (63.68%) after the TDI. Pulp
necrosis was the most common HC (38.3%), and
it was significantly associated with avulsion
(P = 0.023). Teeth with complete RD showed a
tendency of developing HC over time, independent of TDI (P = 0.05). HC in teeth with complete
RD related to support tissue trauma (P = 0.005)
and avulsion (P < 0.001) appeared more frequently after 3 months.
Conclusion. Healing complications are more common in teeth that have suffered trauma in supporting tissues and avulsion, especially in teeth
with complete RD. The HC occur more frequently
in the first 3 months, and a necrotic pulp was the
most common complication.

opment (RD), and bacterial contamination79.

Teeth with complete roots are known to
have less potential for regeneration and
therefore higher chance of complications1,36.
Few studies have evaluated the influence of
RD on the occurrence of HCs in each type of
affected tissue.
Generally, pulp necrosis is the most common HC and is difficult to diagnose in cases
of trauma6,10. Late diagnosis of pulp necrosis
after trauma can result in additional complications, such as apical periodontitis and
inflammatory root resorption6.
Although TDIs require ongoing monitoring,
as HCs can occur weeks, months, or even
several years after the injury7,1114, little is
known about its development over the time.
Thus, this study aimed to describe the health
complications associated with the traumatized
permanent teeth over a 12-month period and
assess the relationship between these complications and TDI, involving tissues and RD.

2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Healing complications of traumatized permanent teeth

Material and methods

This retrospective study evaluated records of

1022 patients (015 years old) who attended
the Dental Trauma Surveillance Center
(DTSC) of the Federal University of Rio de
Janeiro from 2005 to 2011. The professionals
performing the initial examinations, and the
emergency treatments were MSc dental students who had received prior training and
were supervised by a teacher during those
procedures. The study was approved by the
universitys Research Ethics Committee. All
the subjects were treated in accordance with
the Helsinki Declaration, and each subject
participating in this study, along with their
parents, signed consent forms with detailed
information.
Clinical examination
At the time of injury, the following parameters were registered on trauma charts:
affected tissue and tooth, type of injury, and
gingival and bone damage. For each tooth,
clinical information was recorded which
included color of the clinical crown, dislocation, mobility, tenderness to percussion, percussion tone, and thermal sensibility.
Classification of each TDI was made according
to the criteria of Andreasen et al.1.
Radiographic and photographic examination7
Horizontal and axial intraoral photographs
were taken at the time of treatment. Three
periapical radiographs (orto- mesio- and distoradial/angulation), occlusal, and panoramic
exposure were taken at the initial examination. Generally, the standardized long-cone
paralleling technique was used for periapical
radiographic.
Eligibility criteria
Complete medical records of systemically
healthy patients, aged between 6 and
15 years old, with a history of dental trauma
in permanent teeth and a minimum followup of 12 months were included. The records
of patients who missed follow-up visits or

381

who had teeth extracted before they first

arrived at DTSC were excluded, as well as the
records with missing data.
Diagnosis of healing complications
The diagnosis of HCs was based on the clinical and radiographic characteristics1,6. For this
study, HCs were recorded only at the time of
their first diagnosis; therefore, the complications evolution was not evaluated, as patients
were referred elsewhere for treatment.
The International Association of Dental
Traumatology (IADT) protocol recommends
endodontic treatment for avulsed teeth with
complete RD in up to 710 days14. Therefore,
all the cases mentioned above were considered
with necrotic pulp, except for those with other
complication in the first diagnostic moment.
The data collected were gender, age,
affected tooth, TDI, the affected tissue, RD
(complete or incomplete), occurrence of HC,
and when it was diagnosed (03, 06, and
12 months). To evaluate the relationship
between the severity of TDI and the occurrence of HCs, the injuries were grouped
according to the affected tissue (dental, support, dental and support) excluding avulsion,
which was independently analyzed, because
it is considered to be a more severe injury
with a more doubtful prognosis1,14. All data
were analyzed by one calibrated examiner.
The SPSS statistical software (version 16.0;
SPSS Inc., Chicago, IL, USA) was used for
statistical
analysis.
Frequencies
were
described, and the relationship between HCs,
type of affected tissue, and period of diagnosis
was analyzed using chi-squared test. The
trend of the occurrence of a HC over time
according to RD was analyzed using Mantel
Haenszel analysis. The relationship between
the occurrence of HCs, type of affected tissue,
RD, and diagnosis period were analyzed using
relative risk (RR) analysis. The level of significance was 0.05%, and the confidence interval was 95%.
Results

From a total of 352 records of patients with

traumatized permanent teeth, 294 were

2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

382

T. R. C. Soares et al.

selected according to the eligibility criteria.

From these total of records of patients with
TDI, 548 teeth were included in the final
sample.
The mean age was 9.34 (1.980), and boys
(65%) were more affected than girls. The
maxillary central incisors (77.0%) were the
most affected teeth, and just over half had
incomplete RD (52.9%). As shown in Table 1,
enamel and dentin fracture without pulp
exposure (31.8%) was the most common
traumatic injury, followed by avulsion
(12.9%).
Table 2 shows the distribution of various
complications according to the type of tissue
affected and the time at which it was diagnosed. Healing complications were present in
201 (36.68%) teeth and were more frequently diagnosed at 3 months (63.68%)
after the occurrence of TDI. Considering the
whole study period, the most common complication was pulp necrosis (n = 77; 38.31%),
followed by progressive inflammatory resorption (n = 62; 30.85%). In this period, the
pulp necrosis occurred significantly more in
teeth that suffered avulsion (n = 34; 44.1%;
P = 0.023 chi-squared test). Teeth with
enamel fracture (n = 48), independent of RD
had no HCs during the follow-up period.

Table 1. Frequency of Traumatic dental injuries.

Affected tissue
Dental hard
tissue

Dental + Support
Support tissue

Support-Avulsion

Traumatic dental
injury
Enamel fracture
Enamel and dentin
fracture without
pulp exposure
Enamel and dentin
fracture with pulp
exposure
Crownroot fracture
Root fracture
Crown
fractures + luxations
Concussion
Subluxation
Lateral luxation
Extrusive luxation
Intrusive luxation
Avulsion
Total

Absolute
value

Relative
value

48

8.7

174

31.8

25

4.6

7
2
68

1.3
0.4
12.4

19
56
39
22
17
71
548

3.5
10.2
7.1
4.0
3.1
12.9
100.0

For MantelHaenszel analysis, with exception of avulsion, the results showed that teeth
with complete RD showed a tendency to have
complications during the observational periods, regardless of the TDI (P = 0.05), whereas
teeth with incomplete RD did not show the
same trend (P = 0.55).
According to the analysis of RR, patients
with complete root formation showed more
risk of suffering complications in the 3, 6, and
12 months (Tables 3, 4, and 5, respectively).
This result was statistically significant at
3 months after trauma to the support tissue
(RR = 2.69; IC = 1.315.53; P = 0.005) and
to avulsion (RR = 1.86; IC = 1.322.63;
P < 0.001).
Discussion

Traumatic dental injuries that affect permanent

teeth at different stages of RD require monitoring over the long term. Various studies have
shown the occurrence of complications in pulp
and supporting tissues6,12,15,16. In the present
study, HCs in permanent teeth were evaluated
at 3, 6, and 12 months, taking into account the
TDI, the affected tissues, and the RD.
Traumatic dental injuries and RD are
important factors that affect the occurrence of
HCs7. In the present study, the most common
injury was enamel and dentin fractures without pulp exposure, followed by avulsion and
coronary fractures associated with luxations,
which, however, differs from the previous
studies of other authors6,17,18. This can be
explained by the study site, which was a
referral center where the demand for treatment was more frequent in terms of severity
of trauma, esthetic damage, and pain.
Avulsion is considered the most severe
TDI1,14, and in the present study, all patients
showed some type of HC during the 12month follow-up period. Andreasen et al.1
reported that pulp regeneration can be
observed in avulsed teeth with incomplete
RD when there is no diagnosis of HCs at 3
and 6 months. Our results, however, did not
corroborate with this, since at the end of
12 months all avulsed teeth showed HCs. Previous studies1,14,1921 have shown that other
factors such as the extraoral storage medium/

2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Healing complications of traumatized permanent teeth

383

Table 2. Healing complications according to affected tissue in 3, 6, and 12 months.

Period (months)
Healing complication

Affected tissue

Pulp necrosis

Dental
Dental +
Support
Avulsion
Total
Dental
Dental +
Support
Avulsion
Total
Dental
Dental +
Support
Avulsion
Total
Dental
Dental +
Support
Avulsion
Total
Dental
Dental +
Support
Avulsion
Total
Dental
Dental +
Support
Avulsion
Total

09
06
10
32
57
03
06
10
22
41
12
06
05
02
25

01
02
03

02

02

Progressive inflammatory root resorption

Apical periodontitis

Ankylosis

Irreversible Pulpitis

Pulp obliteration

Support

Support

Support

Support

Support

Support

6
(11.7)
(7.8)
(13.0)
(41.5)
(74.0)
(4.8)
(9.7)
(16.1)
(35.6)
(66.2)
(23.1)
(11.4)
(9.6)
(3.9)
(48.0)

(20.0)
(40.0)
(60.0)
(66.7)

(66.7)

03
01
03
01
08

02
04
06
02

01
01
04

01

01
01

01

12
(3.9)
(1.3)
(3.9)
(1.3)
(10.4)

(3.2)
(6.4)
(9.6)
(3.9)
(1.9)
(1.9)
(7.7)

(20.0)
(20.0)
(33.3)

(33.3)

06
02
03
01
12
04
02
05
04
15
16
04
02
01
23

01
01

02

02

(7.8)
(2.6)
(3.9)
(1.3)
(15.6)
(6.5)
(3.2)
(8.1)
(6.4)
(24.2)
(30.8)
(7.7)
(3.9)
(1.9)
(44.3)

(20.0)
(20.0)

(100)
(100)

Total

P value

18
09
16
34
77
07
08
17
30
62
30
10
08
04
52
0
0
02
03
05
01
02
0
0
03
0
0
02
0
02

0.023*

(23.4)
(11.7)
(20.8)
(44.1)
(100.0)
(11.3)
(12.9)
(27.4)
(48.4)
(100.0)
(57.8)
(19.1)
(15.4)
(7.7)
(100.0)
(0)
(0)
(40.0)
(60.0)
(100.0)
(33.3)
(66.7)
(0)
(0)
(100.0)
(0)
(0)
(100.0)
(0)
(100.0)

0.255

0.510

0.329

0.083

Chi-squared test.
*Statistical significance (P 0.05).

Table 3. Healing complications after 3 months according the affected tissue and root development.
Healing complication
Affected tissue

Root development

Yes (%)

No (%)

Total (%)

Dental hard tissue

Incomplete
Complete
Incomplete
Complete
Incomplete
Complete
Incomplete
Complete

13
11
8
12
10
16
15
43

120
112
25
23
86
41
13

133
123
33
35
96
57
28
43

Dental + Support
Support
Avulsion

(9.8)
(8.9)
(24.2)
(34.3)
(10.4)
(28.1)
(53.6)
(100)

(90.2)
(91.1)
(75.8)
(65.7)
(89.6)
(71.9)
(46.4)

(100)
(100)
(100)
(100)
(100)
(100)
(100)
(100)

P value

RR

IC

0.820

0.91

0.421.96

0.364

1.41

0.663.01

0.005*

2.69

1.315.53

<0.001*

1.86

1.322.63

*Statistical significance (P 0.05).

Relative risk analysis.
RR, relative risk; IC, interval confidence (95%).

period and splint conditions interfere with

the development of HCs in cases of avulsion,
but these data are not reported in this study.

In the present study, pulp necrosis was the

most frequent HC and 76.6% occurred with
dislocated teeth. These results concur with

2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

384

T. R. C. Soares et al.

Table 4. Healing complications after 6 months according the affected tissue and root development.
Healing complication
Affected tissue

Root development

Yes (%)

No (%)

Total (%)

P value

RR

IC

Dental hard tissue

Incomplete
Complete
Incomplete
Complete
Incomplete
Complete
Incomplete
Complete

1
5

1
3
4
6

119
107
25
22
83
37
7

120
112
25
23
86
41
13

0.082

5.35

0.6345.14

0.292

0.148

2.79

0.6511.92

Dental + Support
Support
Avulsion

(0.8)
(4.5)
(4.3)
(3.5)
(9.8)
(46.2)

(99.2)
(95.5)
(100)
(95.7)
(96.5)
(90.2)
(53.6)

(100)
(100)
(100)
(100)
(100)
(100)
(100)

Relative risk analysis.

RR, relative risk; IC, interval confidence (95%).

Table 5. Healing complications after 12 months according the affected tissue and root development.
Healing complication
Affected tissue

Root development

Yes (%)

No (%)

Total (%)

P value

RR

IC

Dental hard tissue

Incomplete
Complete
Incomplete
Complete
Incomplete
Complete
Incomplete
Complete

13
13
3
5
9
3
7

106
94
22
17
74
34

119
107
25
22
83
37
7

0.773

1.11

0.532.29

0.329

1.89

0.517.03

0.645

0.74

0.212.60

Dental + Support
Support
Avulsion

(10.9)
(12.1)
(12)
(22.7)
(10.8)
(8.1)
(100)

(89.1)
(87.9)
(88)
(77.3)
(89.2)
(91.9)

(100)
(100)
(100)
(100)
(100)
(100)
(100)

Relative risk analysis.

RR, relative risk; IC, interval confidence (95%).

other studies where the prevalence of pulp

necrosis ranged from 17% to 100% for dislocated teeth69,22. In the 3-month period, teeth
with affected dental tissue associated with
trauma to the supporting tissues showed
more HCs than the teeth that had only dental
hard tissue. These findings were also reported
in the previous studies35,12.
In addition, the most common complications associated with dental tissue were
irreversible pulpitis, apical periodontitis, and
pulp necrosis. All can be related to microbial
contamination of dentinal tubules as
suggested by Robertson et al.12
Both apical periodontitis and inflammatory
resorption are related to the late diagnosis of
pulp necrosis, which is very difficult to diagnose in the first few weeks1,6. According to
Andreasen and Vestergaard7, immediately
after the trauma, approximately half of the
teeth with luxations do not respond to sus-

ceptibility testing. Therefore, the follow-up

protocol is very important for a correct diagnosis.
Inflammatory resorption is considered one
of the most severe HCs, because it progresses
rapidly and is always associated with pulp
necrosis and infection, which can lead to the
loss of the affected tooth6. The present study
concurred with the fact that the majority of
TDIs associated with inflammatory resorption
are support tissue and avulsion21,23. Inflammatory resorption was the most prevalent after
3 months, mainly in luxated and avulsed teeth.
Pulp obliteration was found in cases of
trauma in support tissue (extrusive luxation
of teeth with incomplete RD data not
published). These results corroborate with the
findings of Hecova et al.6, who reported the
pulp obliteration was more often in dislocated
luxations with a lower damage potential,
which is reasonable, as pulp canal obliteration

2013 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Healing complications of traumatized permanent teeth

is a kind of healing. Also, pulp obliteration

can be expected in teeth with incomplete
RD1,12.
Although the teeth with complete RD
appeared to be more prone to have HCs for
the other kinds of affected tissue and others
diagnosed period, only in cases of teeth with
affected support tissue and avulsion, it was
possible to identify a statistical difference
between RD and HCs after 3 months. These
findings are in agreement with other studies
in the literature1,6. Teeth with complete
development have lower risk of scarring due
to the diameter of the apical foramen which
complicates the process of regeneration, especially in cases of dislocation12.
Other factors besides the type of affected
tissue and rhizogenesis may be related to the
development of HCs. A limitation of this
study is related to the difficulty of collection
information from the first attendance (when
it was not performed at DSTC). In these cases,
the Guardians report is our information
source. Thus, studies with retrospective or
prospective design concerning the influence
of factors, such as the first care, the oral
hygiene, the dietary habits, and the inappropriate occlusal contact, on the development
of HCs in traumatized permanent teeth are
still needed and could be essential to enhance
the development of clinical protocols.
In conclusion, the present study found that
HCs are more common in teeth that have suffered trauma in supporting tissues and avulsion, especially in teeth with complete RD.
Furthermore, HC occurred more frequently
within the first 3 months, and necrotic pulp
is the most common complication.

Why this paper is important to Paediatric Dentists

This paper is important to pediatric dentists because it:
Demonstrates how the type of traumatic injury and
RD interfere with the appearance of post-traumatic
complications and can be a guide to diagnosis and
prognosis;
Demonstrates that the first 3 months were considered
the critical period for the diagnosis of complications
after dental trauma;
Demonstrates the complications that can occur long
after a dental trauma, reinforcing the importance of
follow-up.

385

Acknowledgements

The authors would like to thank the Fundao de Amparo Pesquisa do Estado do Rio
de Janeiro (FAPERJ).
Conflict of interest

The authors deny any conflict of interests.

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