Use of ultrasound Doppler to determine tooth

vitality in a discolored tooth after traumatic

injury: its prospects and limitations
Yong-Wook Cho and Sung-Ho Park
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Abstract
When a tooth shows discoloration and does not respond to the cold test or electric pulp test
(EPT) after a traumatic injury, its diagnosis can be even more difficult due to the lack of proper
diagnostic methods to evaluate its vitality. In these case reports, we hope to demonstrate that
ultrasound Doppler might be successfully used to evaluate the vitality of the tooth after trauma,
and help reduce unnecessary endodontic treatments. In all three of the present cases, the teeth
were discolored after traumatic injuries and showed negative responses to the cold test and EPT.
However, they showed distinctive vital reactions in the ultrasound Doppler test during the whole
observation period. In the first case, the tooth color returned to normal, and the tooth showed a
positive response to the cold test and EPT at 10 wk after the injury. In the second case, the tooth
color had returned to its normal shade at 10 wk after the traumatic injury but remained
insensitive to the cold test and EPT. In the third case, the discoloration was successfully treated
with vital tooth bleaching.
Keywords: Tooth discoloration, Tooth vitality, Traumatic injury, Ultrasound Doppler
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Introduction
Tooth vitality is determined using the cold test, electric pulp test (EPT), radiographic
examination, or clinical signs such as tooth discoloration. However, tooth vitality could be more
properly evaluated by the blood supply in the pulp rather than these other tests, such as the cold
test and EPT, which actually evaluate the sensitivity of the nerves.1 When the tooth experience a
traumatic injury, the evaluation of tooth vitality is difficult because they occasionally do not
respond to the cold test or EPT due to the reduced conduction ability of the sensory nerves or
nerve endings.2 This lack of response seems to be caused by the damage, inflammation,
compression or tension state of the apical nerve fibers, which require approximately eight weeks
or more to return to normal functioning.3
Tooth discoloration may follow a traumatic injury.4,5 When the tooth shows discoloration and
also does not respond to the cold test or EPT after a traumatic injury, its diagnosis can be even
more difficult due to the lack of proper diagnostic methods to evaluate its vitality. The discolored
tooth may return to its original shade and translucency completely or incompletely when the
tooth vitality is preserved.4,5 Malgren and Hubel reported that the discoloration disappeared
within 4 weeks to 6 months in eight out of nine permanent teeth that had been root fractured and
showed tooth discoloration after the trauma.6 They reported that all of the teeth had regained
their normal sensibility when the discoloration disappeared. Transient color changes were also
described in connection with transient apical breakdown (TAB) after luxation injuries in
permanent teeth.7,8 The discoloration and loss of electrometric sensibility returned to normal
when there was radiographic evidence of the resolution of the TAB. However, this resolution
usually takes a long time to be confirmed.
Ultrasound Doppler imaging has been used in many medical fields as a non-invasive and
radiation-free technique to assess the blood flow in micro-vascular systems. Ultrasound has also
recently been applied to dentistry. Some studies have shown that ultrasound Doppler imaging
provides sufficient information on micro-vascularity for dental treatment.9-11
Recently, Yoon et al. reported that ultrasound Doppler could be effectively used to evaluate the
pulp blood flow in the pulp spaces.1,12 They reported that it can measure the reduced blood
stream speed after a local anesthetic injection containing 1 : 80,000 epinephrine. They also
indicated the possibility that this Doppler system could be used effectively in the diagnosis of
traumatic injury.12
In this paper, three cases are presented that were seen in the Department of Conservative
Dentistry, Yonsei University Dental Hospital, Seoul, Korea, during the past two years. In the
beginning, all three teeth were discolored after a traumatic injury and showed negative responses
to the thermal test and EPT but also showed a distinctive vital reaction in the ultrasound Doppler
test unit (MM-D-K, Minimax, Moscow, Russia). In the first and second cases, the tooth
discolorations returned to normal at 10 weeks after the injuries. In the third case, the tooth
discoloration was successfully treated by vital bleaching. In this case series, we hope to
demonstrate that ultrasound Doppler might be successfully used to evaluate the vitality of teeth
after trauma and help reduce unnecessary endodontic treatments.
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Case reports
Case 1
A 47-year-old female patient visited our department due to traumatic injury to her upper right
lateral incisor (tooth #12). She sustained the injury 3 days before she visited our clinic by a fist
blow injury to her face. Tooth #12 was subluxated, and showed a positive response to a
percussion test. It did not show any response to a cold test or EPT. The tooth was diagnosed with
subluxation, and we decided to wait and observe its course. There was no discomfort during the
2 weeks after the injury, but there was no response to the thermal test or EPT, and a reddish
discoloration was observed (Figure 1a).

Figure 1
(a) In case 1, discoloration of tooth #12 was observed at 2 weeks after the injury; (b) The result
of an ultrasound Doppler test at 6 weeks after the injury. It shows a typical pulsated image,
which represents normal vital pulp; (c) At 10 weeks after ...
At 6 weeks after the injury, the patient did not show any discomfort, but the discoloration lasted,
and the tooth did not respond to cold or EPT. We decided to use the ultrasound Doppler unit to
evaluate the vitality of the pulp, and the result was shown in Figure 1b. Tooth #12 produced a
typical pulsated image, which represents normal vital pulp (Figure 1b). We explained the results
and implications of the test to the patient. We decided to continue to wait and observe the tooth
because the patient had no discomfort, did not mind the discoloration at that time, and was
willing to wait to determine whether the tooth could recover to normal without any treatment. At
10 weeks after the injury, the tooth had returned to a normal shade and regained its normal
responses to the cold test and EPT (Figure 1c).
Case 2
A 30-year-old female patient visited our clinic for further treatment of traumatized anterior teeth.
She had sustained an injury from a fall 2 weeks ago, and had visited a local clinic immediately
after the trauma. The subluxated tooth #21 was splinted with composite resin and wire from
tooth #13 to tooth #23, and then the local dentist referred her to our clinic. In the periapical
radiographic view, the root and periapical area were normal (Figure 2a). Tooth #21 showed
negative responses to the thermal test and EPT, a positive response to the percussion test, and
pinkish discoloration (Figure 2b). The other teeth showed normal responses to all of the tests. In
the ultrasound Doppler test, tooth #21 produced a normal pulsated response like those of the
other teeth, and we were also able to hear the beat of the pulsation from the speaker (Figure 2c).
At 4 weeks after the injury, tooth #21 showed normal response to percussion, again. In the other
tests, the results were also the same as in the previous visit. At 6 weeks after the injury, tooth #21
still showed pinkish discoloration and negative responses to the thermal test and EPT. At 10
weeks after the injury, the shade of tooth #21 returned to normal (Figure 2d). At 12, 16, 20, and
24 weeks after the injury, the patient did not feel any discomfort at all. In the ultrasound Doppler
test, tooth #21 showed a vital response, but it did not respond to the cold test or EPT. In the
periapical view, the root and periapical area were within the normal range. The negative response
continued throughout the follow-up period for 9 months. At that time, she was pregnant and
wanted to delay her next visit until after her delivery.

Figure 2
(a) In case 2, tooth #21 was splinted at a local clinic after a subluxation injury that had occurred
2 weeks before the patient visited our clinic. It showed a negative response to the thermal test
and EPT, and a positive response to the percussion test; ...
Case 3
A 22-year-old female patient visited our department to have her teeth bleached. She thought her
teeth were generally yellowish, and she was especially unsatisfied with the shade of tooth #11,
which showed yellowish brown discoloration (Figure 3a). She reported experiencing trauma to
her anterior teeth when she was in primary school, and she had finished orthodontic treatment
approximately 7 years before presentation. However, she did not know exactly when tooth #11
started to become discolored. In the radiograph, the coronal pulp space was obliterated, whereas
the pulp space was present in the root area. There was no radiolucency in the periapical region,
but the root apex was slightly shortened (Figure 3b). In the cold test, tooth #11 did not show any
response, although she occasionally displayed a delayed response. The tooth did not respond to
the EPT. In the ultrasound Doppler test, tooth #11 showed an image and sound typical of a vital
tooth (Figure 3c). We decided to perform vital tooth bleaching first and then re-evaluate the color
to decide whether restorative treatment was needed. Home bleaching was started using 15%
carbamide peroxide gel (Opalescence, Ultradent, South Jordan, UT, USA). Additional home
bleaching was continued only for tooth #11 after she was satisfied with the shade of her other
teeth. After approximately 2 months of bleaching, she was satisfied with the shade of tooth #11
and did not want any further treatment (Figure 3d).

Figure 3
(a) In case 3, tooth #11 showed yellowish brown discoloration; (b) The coronal pulp space was
obliterated, whereas the pulp space was present in the root area. There was no radiolucency in
the periapical area, but the root apex was slightly shortened; ...
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Discussion
Pink discoloration, which may occur within 2 - 3 days after a traumatic injury, is caused by the
rupture of capillaries and the release of red blood cells into the pulp chamber. Hemolysis leads to
the diffusion of hemoglobin into the dentinal tubules, which shift the tooth color from pinkish to
grayish-blue. Some fading of the grey-blue tint can occur when the blood supply to the pulp is
maintained and the pulp survives.6
In the first case, the ultrasound Doppler showed a typical pulsated image when the tooth did not
respond to the cold test and EPT in the early phase after a traumatic injury. Then, in ongoing
follow-up, the Doppler test continued to show vital image, but the tooth still did not respond to
the other two tests. The tooth regained its shade by 10 weeks after the traumatic injury, and its
response to the cold test and EPT returned to normal. This finding is consistent with previous
reports that indicated that the discoloration returned to normal when the teeth regained their
vitality and demonstrating that ultrasound Doppler can be successfully used to determine the
vitality of teeth during the period when they do not respond to the cold test and EPT after a
traumatic injury.4-8 Ultrasound Doppler may help decrease unnecessary endodontic treatments,
which could be performed due to a lack of the proper diagnostic methods after a traumatic injury.
In the first and second cases, 10 weeks were needed to regain the tooth's color and responses to
the cold test and EPT. This result is consistent with a previous study in which the discoloration
disappeared within 4 weeks to 6 months after root fracture resulting in tooth discoloration after
trauma.6 The second case was interesting in that the discoloration returned to normal by 10
weeks after injury, but the tooth did not respond to the cold test and EPT even at 9 months after
the traumatic injury, although it showed a consistent vital image in the Doppler test from the
beginning. False positive responses in the ultrasound Doppler test have not yet been studied. In
the present study, a 20-MHz ultrasound Doppler probe was used. The frequency of ultrasound is
very important because it determines the penetration depth of the ultrasound wave. Although a
20-MHz frequency was reported to efficiently penetrate the enamel and dentin, and detect the
blood flow in the pulp spaces, it might be possible to detect the blood flow outside of the pulp
spaces if the thickness of the hard tissue is very thin.1,12 The potential for false positive
responses with the ultrasound Doppler probe requires further investigation. In the second case,
long-term follow-up is necessary to verify whether the vitality was actually maintained, which
could be confirmed by a positive response to the cold test and EPT. However, in this case, the
tooth returned to its normal shade by 10 weeks after the traumatic injury, which suggests that the
blood supply to the pulp was maintained and the pulp survived.6 More time might be needed for
the nerve fiber to heal. Further follow-up is required to determine whether the test results are true
or false positive.
In the third case, the patient did not respond to the cold test and EPT, although she occasionally
showed an obscure positive delayed response to the cold test. The cold test depends on the
hydrodynamic movement of fluid within the dentinal tubules, which excites the A-fibers.13
Teeth with calcified pulp spaces might have normal and healthy pulps, but cold stimuli might not
be able to excite the nerve endings due to the insulating effect of the thicker layer of dentin,
which is the result of secondary and reactionary dentin formation.14 Ehrmann reported that EPT
is particularly effective in older patients and in teeth that have limited fluid movement through
the dentinal tubules as a result of dentine sclerosis and calcification of the pulp space because
thermal pulp tests are usually inadequate in these situations.14 Klein reported that a patient was
unlikely to respond to a cold test but may respond to an EPT if the pulp space had been
significantly calcified.15 In their case, more electric pulp current was often needed to elicit a
response because there was an increased dentin layer and a diminished pulp cavity or a fibrotic
pulp. In the third case, tooth #11 was diagnosed as a vital tooth based on the results of the
ultrasound Doppler test because it displayed a consistent positive sign throughout the observation
period. In this case, the coronal pulp space was obliterated, whereas the pulp space was present
in the root area. Because the ultrasound Doppler probe tip was positioned apically, there was a
possibility of detecting the blood flow of the root canal. Furthermore, the patient showed a
response to the cold test, although the response was delayed and inconsistent. For further
research, we need more cases and studies related to ultrasound Doppler.
Other methods for evaluating the vascularity of pulp are laser Doppler and pulse oximetry.16-20
Laser Doppler applies a laser to transmit light into the pulp blood vessels through the tooth
structure, and a red and infrared LED light beam is used in pulse oximetry for the same purpose.
However, the discoloration of the tooth caused by the deposition of blood pigments in the
traumatized tooth may hinder the penetration of light in both laser Doppler and pulse
oximetry.18,20,21 The ultrasound wave used in the ultrasound Doppler unit can detect blood
flow regardless of coronal discoloration, so it can be more useful for discolored teeth.
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Conclusions
Tooth discoloration after a traumatic injury was corrected when the ultrasound Doppler produced
a typical pulsated image, which represents normal vital pulp. Ultrasound Doppler might be an
effective tool to evaluate tooth vitality when the cold test and EPT do not give proper
information, especially after a traumatic injury. However, the use of ultrasound Doppler requires
further research on the potential for false positive and negative responses to increase its clinical
reliability.
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Acknowledgement
This case report is a part of the research that was supported by the Basic Science Research
Program through the National Research Foundation of Korea (NRF) funded by the Ministry of
Education, Science and Technology (2011-0021235).
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Footnotes
No potential conflict of interest relevant to this article was reported.
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References
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assess pulp vitality. J Can Dent Assoc. 2009;75:139143. [PubMed]
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4. Aguil L, Ganda JL. Transient red discoloration: report of case. ASDC J Dent Child.
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5. Andreasen FM. Pulpal healing after luxation injuries and root fracture in the permanent
dentition. Endod Dent Traumatol. 1989;5:111131. [PubMed]
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fractures. Dent Traumatol. 2012;28:200204. [PubMed]
7. Andreasen FM. Transient apical breakdown and its relation to color and sensibility changes
after luxation injuries to teeth. Endod Dent Traumatol. 1986;2:919. [PubMed]
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Traumatol. 2003;19:289291. [PubMed]
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Aust Dent J. 1977;22:272279. [PubMed]
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dentition. ASDC J Dent Child. 1978;45:199202. [PubMed]
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luxated permanent teeth. Int Endod J. 1988;21:300306. [PubMed]
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Abstract
Objectives
Vertical root fractures (VRFs) are a common cause of tooth loss. Little evidence exists though,
relating the incidence of VRFs to the type of endodontic retreatment. This retrospective study
aimed at evaluating the impact of conventional versus surgical endodontics on root canal-filled
teeth with VRFs.
Materials and methods
Over a period of 13 years, 200 endodontically retreated teeth from 192 patients with VRFs were
extracted and further examined. VRFs were assessed in relation to age, gender, tooth group,
clinical signs, extension on the root surface, patency, as well as type of endodontic retreatment
and restoration. Statistical analysis was conducted using a Cox PH Model, Chi-squared,
Wilcoxon rank-sum, and Log rank tests at a significance level of 5 %.
Results
The majority of teeth with VRFs (62.31 %) had undergone the combination of conventional root
canal retreatment and apical surgery. Women (64.06 %) presented VRFs more frequently than
men (35.94 %) at the mean age of 51.1 and 55.1 years, respectively. Maxillary first (17.5 %) and
second (16.5 %) premolars, restored by a resin-based material without a post (56.28 %) were
more susceptible to VRFs. Apically initiated (84.1 %) VRFs could be diagnosed more easily on
radiographs.
Conclusions
The type of endodontic treatment strongly correlated with VRFs. The prevalence of VRFs in
teeth having undergone both conventional and surgical endodontic retreatment could be
attributed, among others, to additive dentin damage related to the aforementioned endodontic
procedures.
Clinical relevance
The possible involvement of endodontic retreatment in the multifactorial etiology of VRFs needs
to be taken into consideration in clinical practice.
Original Article
Comparative assessment of the incidence of
vertical root fractures between conventional
versus surgical endodontic retreatment
L. Karygianni
1
, M. Krengel
2
, M. Winter
3
, S. Stampf
4
and K. T. Wrbas
1, 5

(1)
Department of Operative Dentistry and Periodontology, Center for Dental Medicine, Medical
Center, University of Freiburg, Hugstetterstrasse 55, Freiburg, 79106, Germany
(2)
Bergisch Gladbach, Germany
(3)
Rheinbach, Germany
(4)
Institute of Medical Biometry and Medical Informatics, Albert-Ludwigs-University, Freiburg,
Germany
(5)
Department of Endodontics, Centre for Operative Dentistry and Periodontology, University of
Dental Medicine and Oral Health, Danube Private University (DPU), Krems, Austria


K. T. Wrbas
Email: thomas.wrbas@uniklinik-freiburg.de
Received: 8 August 2013Accepted: 26 December 2013Published online: 10 January 2014
Abstract
Objectives
Vertical root fractures (VRFs) are a common cause of tooth loss. Little evidence exists though,
relating the incidence of VRFs to the type of endodontic retreatment. This retrospective study
aimed at evaluating the impact of conventional versus surgical endodontics on root canal-filled
teeth with VRFs.
Materials and methods
Over a period of 13 years, 200 endodontically retreated teeth from 192 patients with VRFs were
extracted and further examined. VRFs were assessed in relation to age, gender, tooth group,
clinical signs, extension on the root surface, patency, as well as type of endodontic retreatment
and restoration. Statistical analysis was conducted using a Cox PH Model, Chi-squared,
Wilcoxon rank-sum, and Log rank tests at a significance level of 5 %.
Results
The majority of teeth with VRFs (62.31 %) had undergone the combination of conventional root
canal retreatment and apical surgery. Women (64.06 %) presented VRFs more frequently than
men (35.94 %) at the mean age of 51.1 and 55.1 years, respectively. Maxillary first (17.5 %) and
second (16.5 %) premolars, restored by a resin-based material without a post (56.28 %) were
more susceptible to VRFs. Apically initiated (84.1 %) VRFs could be diagnosed more easily on
radiographs.
Conclusions
The type of endodontic treatment strongly correlated with VRFs. The prevalence of VRFs in
teeth having undergone both conventional and surgical endodontic retreatment could be
attributed, among others, to additive dentin damage related to the aforementioned endodontic
procedures.
Clinical relevance
The possible involvement of endodontic retreatment in the multifactorial etiology of VRFs needs
to be taken into consideration in clinical practice.
Keywords
Apical surgery Clinical signs Endodontic retreatment Vertical root fractures
Introduction
Novel NiTi retreatment systems and root canal obturation techniques allow for minimized dentin
loss of root canals during endodontic procedures and thus, for fracture resistance of root canal-
treated teeth in the long term [1]. However, these vast improvements in modern endodontics are
still accompanied by the unexpected occurrence of vertical root fractures (VRFs) in root canal-
treated teeth. According to the American Association of Endodontists, vertically fractured teeth
are characterized by a crack that begins in the root at any level and extends toward the occlusal
surface, usually in the bucco-lingual direction [2].
The diagnosis of VRFs, usually years after the final crown restoration of the root canal-treated
teeth, may be confusing because of the existence of nonspecific radiographic and clinical signs
that imitate endodontic treatment failure or periodontal disease [3, 4]. Representative clinical
features of VRFs usually include a deep, thread-thin, isolated periodontal pocket, and multiple
sinus tracts, sometimes situated coronally on both the buccal and lingual gingiva [5].
Furthermore, an angular resorption pattern (halo lesion) which incorporates a periapical along
with a lateral radiolucency extending apically has been shown as a typical radiographic feature of
VRFs on conventional X-rays [6]. High-resolution visualization techniques with image accuracy
and low radiation doses such as local CT, tuned-aperture computed tomography, and optical
coherence tomography have been also successfully employed for monitoring VRFs [7, 8].
Nevertheless, when the diagnosis of a VRF is still inconclusive, exploratory surgical procedures
are usually applied to verify its occurrence [6].
Clinical management has to be undertaken as soon as possible to prevent additional bone loss,
which might pose difficulties for the further reconstruction of the region later on. Vertically
fractured teeth inevitably lead to extraction in most of the cases. Alternative treatment
procedures involve extraction only of the fractured root in multirooted teeth [9, 10]. Some
authors suggest also removing the fractured tooth and rebonding the fractured parts extraorally
followed by the reimplantation of the tooth [11, 12]. The introduction of cone-beam computed
tomography in dentistry facilitated the three-dimensional high-resolution visualization of VRFs
[13, 14].
The higher incidence of VRFs in root canal-treated teeth is mainly attributed to factors relating to
conventional root-canal treatment such as excessive biomechanical preparation and extreme
lateral-vertical forces during compaction of root canal filling materials [1517]. The use of
irrigants (NaOCl, EDTA) and intracanal medicaments (Ca(OH)
2
) for more than 30 days can also
induce VRFs [18]. Additionally, tooth structural loss is mainly due to dehydration of dentine and
microbe-induced degradation or modification of collagen constitutes risk factors for fracture
predisposition in root canal-treated teeth [19]. Various restorative parameters such as insufficient
ferrule effect, extreme widening of the root canal for posttreatment, and inappropriate postdesign
may all contribute to VRF formation [20, 21].
Nowadays, the widespread conduction of endodontic surgery is considered an alternative
approach with good prognosis in cases where an orthograde attempt at retreatment is not
indicated [22]. Despite that modern microtechniques coupled with the appropriate surgical
magnification have been introduced, VRFs relating to apical surgery may still occur. The
removal of the apical part of the root, the use of specially designed ultrasonic tips as well as the
retrograde MTA filling are treatment parameters that may be associated with VRFs in the
framework of their multifactorial etiology.
The purpose of the present retrospective study was to evaluate potential etiological, clinical, and
radiographic features of 200 root canal-treated teeth referred for extraction after a clinical
diagnosis of VRF. All teeth had received an endodontic retreatment previously, either by a
conventional root-canal retreatment, root-end resection or the combination of both techniques.
Materials and methods
Inclusion and exclusion criteria
The cross-sectional study was conducted over a period of 13 years in a total of 192 patients with
200 root canal-retreated teeth with a diagnosis of VRF. The vertically fractured teeth that were
selected for this study had received endodontic treatment by general practitioners. It could be
assumed that the prevailing quality guidelines for endodontic treatment at that time were
followed to eliminate procedural complications [23]. However, if the quality of the root canal
retreatment controlled by another endodontist prior to the study was questionable, the teeth were
excluded from the study. Based on the type of endodontic retreatment they had received, the
teeth were divided into three groups. In the first group, a conventional retreatment had been
conducted; the second group had undergone apical surgery and the third group had been treated
by both methods. Endodontic retreatment of all teeth had been completed at least 2 years earlier.
In all cases, retreatment was conducted after the initial root canal treatment had been considered
a failure.
Teeth with VRF were finally excluded from the amount of teeth studied if patient records lacked
sufficient information about dental history of the fractured tooth or if the extraction was
associated with dental trauma as well as other types of tooth fractures. Teeth with insufficient
coronal restorations, with direct exposure of the root canal filling material to the oral cavity or
with obturation material that did not reach within 2 mm of the radiographic apex were also
excluded from the study.
Clinical procedure
When the inclusion criteria were fulfilled, the following clinical parameters were further
evaluated by an endodontist: gender and age of the patient, endodontic history, tooth type
(incisor, premolar, or molar in upper/lower jaw), clinical signs (depth and extent of periodontal
pockets and presence of sinus tract and pus), type of endodontic retreatment (conventional
retreatment, root-end resection, and combined use of both methods), and type of definite
restoration (composite, post, and crown). Radiographic alterations were detected with the aid of a
view-box with background illumination and magnification; loss of attachment was demonstrated
as a deep, narrow, isolated periodontal pocket; and distinct separation of the cracked tooth
fragments was diagnosed on X-rays. Exploratory surgery was additionally conducted to confirm
an uncertain diagnosis. The use of magnifying loops (Carl Zeiss, Oberkochen, Germany) and
staining with methylene blue solution along fractures enabled the operator not only to visualize
the fracture lines but also to identify the extension of the fracture on the root surface (apical,
central) and patency of fractures depending on separation of root fragments (complete,
incomplete). All vertically fractured teeth were finally extracted by two oral surgeons, collected
and stored in a 0.9 % saline solution at 4 C until use.
Statistical analysis
Frequency tables and cross tables were used for the statistical evaluation of the data. To evaluate
associations between categorical variables, the Chi-squared test was used. The Wilcoxon rank
sum test was applied to detect significant differences in age between gender groups.
The analysis for evaluating differences between treatment groups was performed with a Cox PH
model and corresponding KaplanMeier curves were presented. The log rank test was used to
examine the difference between patients with different endodontic treatment. All statistical tests
were done at the significance level of 5 % and were performed using the statistical software SAS
9.1.2.
Results
Type of endodontic treatment
Orthograde endodontic retreatment had been performed in 31.16 % of the teeth, whereas root-
end resection had been conducted in only 6.5 % of the root-filled teeth. The majority of the
vertically fractured teeth (62.31 %) had undergone the combination of conventional root canal
retreatment and apical surgery. Moreover, after a maximum period of 4.4 years following only
apical surgery all teeth were diagnosed with VRFs, whereas teeth which had been treated by both
nonsurgical endodontic retreatment and root-end resection were diagnosed after a longer
maximum period of 20 years. Box plots illustrating the time periods between the different types
of endodontic treatment and detection of VRFs are shown in Fig. 1.

Fig. 1
Box plots demonstrating the detection times of vertically fractured teeth in relation to different
types of endodontic retreatment. The central line is the median; whiskers indicate minimum and
maximum. After a maximum period of 4.4 years following only root-end resection (RER) all
fractured root-filled teeth were diagnosed with VRFs, whereas all teeth which had been treated
by both root canal retreatment and root-end resection (RCT + RER) were diagnosed after a
longer maximum period of 20 years
Gender and age
The percentages of female and male patients demonstrating VRFs were 64.06 and 35.94 %,
respectively. The mean age of patients presenting VRFs was 52.6 (13.5; range, 22 to 79) years.
The mean age of female and male patients with VRFs was 55.1 (13.1; range, 22 to 78) years
and 51.1 (13.5; range, 22 to 79) years, respectively. This difference in age between gender was
significant (p value = 0.02, Wilcoxon rank-sum test).
Tooth group
The most commonly extracted teeth were the maxillary first premolars (n = 35, 17.5 %),
maxillary second premolars (n = 33, 16.5 %), maxillary central and lateral incisors (n = 24,
12 %), mandibular first molars (n = 23, 11.5 %), mandibular second premolars (n = 23, 11.5 %),
and maxillary canines (n = 23, 11.5 %). There were very few extracted mandibular and maxillary
second molars as well as mandibular incisors (n = 3, 1.5 %).
Clinical signs
The presence of deep periodontal pockets (23.9 %) was revealed along with the presence of a
sinus tract without pus (28.93 %), sinus tract with pus (3.31 %) and combination of periodontal
pocket and fistula (43.8 %).
Extension of VRF on the root surface
After the extraction of the vertically fractured teeth the extension of VRFs on the root surface
was assessed macroscopically using magnifying loops (Carl Zeiss, Oberkochen, Germany). If the
localization of the fracture line was difficult (especially by incomplete VRFs) staining with
methylene blue solution along fractures enabled the inspection and categorization of VRFs
(coronal, central, and apical) according to their extension on the root surface (Fig. 2). The
extension point of VRFs was located apically in 56.77 % of the teeth which were
macroscopically examined, whereas 43.23 % of the fractures reached the middle of the root
surface. The mean distance measured between the extension point of VRFs and the cement
enamel junction was 5.8 (3.5; range, 1 to 15) mm.

Fig. 2
A vertically fractured mandibular first molar (46) with a fracture line reaching the middle third
of the root surface. According to their extension point on the root surface (coronal third, middle
third, and apical third), vertical root fractures (VRFs) were characterized as coronal, central, and
apical, respectively. CEJ cementenamel junction
Partial/complete VRFs
Based on separation of root fragments, 57.39 % of the VRFs were incomplete, whereas 42.61 %
were complete. The inspection of the VRFs was conducted both radiographically (mainly
complete VRFs) and visually (partial VRFs) with magnifying loops after the extraction of the
vertically fractured teeth. Teeth with VRFs that could not be extracted under atraumatic
conditions were excluded from the study in order to avoid the risk of turning an incomplete VRF
into a complete one.
Radiographic diagnosis
Almost only half of the total amount of VRFs (56.5 %) was radiographically recognizable. There
was a statistically significant association between radiographically recognizable VRFs and their
location on the root. It was found that apically initiated VRFs were more easily observed on the
radiographs (84.1 %) compared with the centrally located fractures (p < 0.001, Chi-square test).
Type of restoration
One hundred twelve teeth (56.28 %) had been previously coronally restored by resin-based
composite without a post, 25 teeth (12.56 %) had been restored by a composite material with a
post, 15 teeth (7.54 %) with posts were crowned, and 47 teeth (23.62 %) were only crowned.
An overview of the major findings of this study relating different clinical and radiographic
parameters to VRFs after conventional root-canal retreatment, root-end resection or the
combination of both techniques is presented in Table 1.
Table 1
Overview of the correlation between various clinical and radiographic parameters and vertical
root fractures (VRF) according to the type of endodontic retreatment
Parameters
relating to
VRFs
Types of endodontic retreatment
Conventional
retreatment
Apical
surgery
Conventional
retreatment + apical
surgery
Total
(n)
Percentage
in %
Exact test
significance
(p value)
Gender
0.011
Women 33 11 79 123 64.06
Men 29 2 38 69 35.04
Age
50 years 16 5 58 79 41.15
> 50 years 42 8 63 113 58.85
Type of tooth
Maxilla
0.0001
Maxillary
central and
lateral incisor
6 1 17 24 12
Maxillary
canine
12 1 10 23 11.5
Maxillary 1st
premolar
5 2 28 35 17.5
Maxillary 2nd
premolar
15 3 15 33 16.5
Maxillary 1st
molar
0 0 10 10 5
Maxillary 2nd
molar
0 1 2 3 1.5
Mandible
Mandibular
central and
lateral incisor
2 0 1 3 1.5
Mandibular
canine
1 1 1 3 1.5
Mandibular 1st
premolar
4 2 12 18 9
Mandibular 2nd
premolar
6 1 16 23 11.5
Mandibular 1st
molar
9 1 12 22 11
Mandibular 2nd
molar
3 0 0 3 1.5
Parameters
relating to
VRFs
Types of endodontic retreatment
Conventional
retreatment
Apical
surgery
Conventional
retreatment + apical
surgery
Total
(n)
Percentage
in %
Exact test
significance
(p value)
Clinical signs
Periodontal
pocket
11 1 17 29 23.97
0.95
Sinus tract
without pus
13 1 21 35 28.93
Sinus tract with
pus
1 0 3 4 3.31
Periodontal
pocket + sinus
tract
21 3 29 53 43.8
Initiation of VRF
Central 20 2 45 67 56.49
0.65
Apical 25 5 57 87 43.51
Patency of VRF
Complete 18 3 28 49 42.98
0.65
Incomplete 21 2 42 65 57.02
Radiographic diagnosis
Yes 41 3 69 113 56.5
0.6
No 22 10 55 87 43.5
Type of restoration
Resin-based
composite
32 4 76 112 56.28
0.01
Resin-based
composite + post
20 0 5 25 12.56
Crown 4 8 35 47 7.54
Crown + post 8 1 6 15 23.62
Discussion
The susceptibility of root canal-filled teeth to VRFs is highlighted in some recent reports [24
26]. The innovation of the present study is that it relates the type of endodontic retreatment with
the incidence of VRFs. Specifically, orthograde endodontic retreatment had been previously
performed in 31.16 % of the teeth, whereas 62.31 % of the vertically fractured teeth had
undergone the combination of root canal retreatment and root-end resection. 6.5 % of the teeth
had been retreated only with root-end resection. Procedures associated to the initial endodontic
treatment such as the use of irrigants, medicaments, and root canal fillings can pave the way for
the occurrence of VRFs [17, 18, 27]. The additional influence of the low moisture content and
the reduced structural tooth integrity after access cavity preparation are also common VRF-
predisposing side effects of the conventional root canal therapy [19]. However, a more profound
damage is made to dentin during retreatment procedures. The additional mechanical widening of
the canal system for the efficient removal of the old root canal filling, the use of various
dissolving agents to soften gutta-percha as well as the removal of separated instruments and
posts can cumulatively promote the defect progression in dentin [2830].
Topical anomalies or more extensive pre-existing flaws located in the canal wall can induce
subcritical cracks resulting in catastrophic root fractures after cyclic loading or immense occlusal
stress [31]. Given also the fact that circumferential and radial stresses on root dentin are doubled
by the presence of a root canal itself, the excessive removal of the apical part of roots, the
application of ultrasonic instruments and retrograde filling materials as well as the mechanical
stress during surgical endodontic procedures could further trigger comprehensive stress at the
root surface and hence crack initiation [32]. The anisotropic mechanical properties of dentin
because of the orientation of the tubules still challenges further research in this field [33].
Nevertheless, the effects of additional potentially harmful procedures during apical surgery are
reflected in the higher incidence of VRFs (62.31 %) among teeth having undergone the
combination of root canal retreatment and root-end resection. Excluding the cases where the
conventional root canal therapy or retreatment failed because of pre-existing VRFs, it seems that
the cumulative dentine damage associated with the initial endodontic treatment, retreatment and
apical surgery could be possibly responsible for the outstanding presence of VRFs in teeth
having undergone both conventional and surgical retreatment.
The multifactorial origin of VRFs in root canal-treated teeth has been well studied, so far. The
influence of chemical agents (irrigants, intracanal medicaments), obturation biomaterials (gutta-
percha, sealer), instrumentation and compaction techniques as well as restorative parameters
(posts, crowns) in VRF predilection in teeth after initial endodontic treatment has been
highlighted in previous studies [1719, 2729]. Nonetheless, endodontic retreatment procedures
are not similar and thus, not comparable to the initial endodontic therapy. Root canals
undergoing endodontic retreatment are subjected to additional preparation for the removal of the
old obturation material, the use of different irrigants, ultrasonication, and the retrieval of posts
and separated files. Given the different treatment protocols followed during retreatment cases
resulting in additional stress of root canal walls, the comparison to primary cases was not
considered meaningful in this report.
The fact that the root-canal treatments were conducted by general practicioners was one of the
limitations of this study. Nevertheless, teeth were excluded from the study if the quality of the
root canal retreatment was questionable. Under-/overinstrumented and insufficiently filled root
canals were therefore rejected as they would compromise the results of this study.
As far as the detection time of VRF in the vertically fractured teeth is concerned, all surgically
retreated teeth without conventional retreatment were diagnosed after 4.4 years. All
nonsurgically retreated teeth following apical surgery were diagnosed with VRF after a longer
period of 20 years. The delayed VRF diagnosis and thus, tooth removal in these cases can be
attributed to the time-consuming treatment sessions as well as long inter-appointment,
observation and recall periods in the framework of orthograde endodontic retreatment. Secondly,
given their great desire to retain the tooth, patients having received nonsurgical retreatment
probably seeked for dental procedures as conservative as possible in order to postpone or even
avoid the extraction of the fractured teeth. Finally, the role of the dentist should also be taken
into account. Specialized endodontists conducting conventional retreatment usually possess
dental operating microscopes allowing for better discrimination of anatomic variations, control
of instruments and prevention of intraoperative complications prior to surgery [34].
The gender distribution manifests a higher incidence of VRFs in women, a finding that
contradicts with the results of other studies, where they are equally divided [35, 36]. The
assumption that bleaching usually preferred by female patients attributes to dentin dehydration
and thus to crack initiation seems a plausible explanation for this phenomenon [37]. Although it
is difficult to ascertain why women have a higher degree of VRFs, it is much easier to surmise
why older patients are prone to VRFs. Teeth of older patients that are longer in everyday use are
more likely to receive root canal therapy over the years. The propensity of VRFs in older
population is also related to low moisture content in dentine, closure of dentin tubules followed
by an increased mineral concentration in dentin, as well as decrease in fracture toughness and
fatigue crack growth resistance with advancing patient age [32, 3840].
Maxillary first premolars (n = 35, 17.5 %) and maxillary second premolars (n = 33, 16.5 %) were
found to have more VRFs than any other tooth, a fact which is consistent with other studies [41,
42]. The combination of all the maxillary and mandibular premolars constituted about 56 % of
all the teeth seen with VRFs.
Despite that deep, narrow, osseous periodontal defects were present in many cases of VRFs
(23.9 %), the simultaneous occurrence of sinus tracts showed significantly higher rates (43.8 %)
invertically fractured teeth. However, the absence of the aforementioned clinical signs was
verified in more than half of the VRFs examined, a fact that highlights the lack of specific
clinical features for the diagnosis of VRFs. A recent report demonstrated a strong correlation
between periodontal pockets and VRFs [43].
The radiographic diagnosis of VRFs can be a very challenging task. Although the detection of
VRFs on radiographs is theoretically possible, the X-ray beam must be aligned with the fracture
to enable its observation. Considering this technical restriction, radiographs have been proved an
unreliable method for the diagnosis of VRFs [44]. Their low sensitivity to detect longitudinal
fractures can be further attributed to the superimposition of other structures [13]. The
development of three-dimensional intraoral radiography systems such as cone-beam computed
tomography or digital volume tomography has facilitated a more accurate visualization of
vertically fractured teeth and their adjacent structures. [14]. The present study confirmed that
only about half of the VRFs (56.5 %) examined were radiographically recognizable.
Nonetheless, the detection of apically extended VRFs on X-rays is probably more feasible
because of their greater extension on the root surface compared with the centrally extended
fractures.
The type of definite restoration plays an essential role in the process of fracturing [26]. Within
the limitations of the present cross-sectional study, the use of resin composite as filling material
appears to increase the susceptibility of root canal-treated teeth to VRFs. However, the presence
of posts combined with composite restorations or with crowns seemed to prevent the appearance
of VRFs despite that in some studies they increased fracture risk because of the stress they
caused to dentin [40, 45]. It is generally believed that the least intraradicular stress is produced
by fiber reinforced composite posts [46]. Nevertheless, posts should be utilized only in cases
where there is little remaining tooth structure and hard tissue supports the apical portion of the
post [21, 22].
Acknowledgments
The authors express their gratitude to Dr. Fadil Elamin, Jonathan Bass, and Dr. Dougal Laird for
their valuable scientific and linguistic contribution to this report.
Conflict of interest
We declare that this manuscript is original, has not been published before and is not currently
being considered for publication elsewhere. We wish to confirm that there are no known
conflicts of interest associated with this publication and there has been no significant financial
support for this work that could have influenced its outcome. The manuscript has been read and
approved by all named authors.

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47. Pulpal sequelae after trauma to
anterior teeth among adult Nigerian
dental patients
48. Adeleke O Oginni
1
and Comfort A Adekoya-Sofowora
2

49. (1)
50. Department of Restorative Dentistry, Faculty of Dentistry, College of Health Sciences,
Obafemi Awolowo University, Ile-Ife, Nigeria
51. (2)
52. Department of Child Dental Health, Faculty of Dentistry, College of Health Sciences,
Obafemi Awolowo University, Ile-Ife, Nigeria
53.
54.
55. Adeleke O Oginni (Corresponding author)
56. Email: adelekeoginni@yahoo.co.uk
57.
58. Comfort A Adekoya-Sofowora (Corresponding author)
59. Email: casofowora@yahoo.com
60. Received: 20 December 2006Accepted: 31 August 2007Published online:
31 August 2007
61. Abstract
62. Background
63. Epidemiological studies show that about 11.6% to 33.0% of all boys and about 3.6% to
19.3% of all girls suffer dental trauma of varying severity before the age of 12 years.
Moderate injuries to the periodontium such as concussion and subluxation are usually
associated with relatively minor symptoms and hence may go unnoticed by the patient or
the dentist, if consulted. Patients with these kinds of injuries present years after a
traumatic accident most of the time with a single discoloured tooth. This study sets out to
document the incidence of various posttraumatic sequelae of discoloured anterior teeth
among adult Nigerian dental patients.
64. Methods
65. One hundred and sixty eight (168) traumatized discoloured anterior teeth in 165 patients
were studied. Teeth with root canal treatment were excluded from the study. Partial
obliteration was recorded when the pulp chamber or root canal was not discernible or
reduced in size on radiographs, total obliteration was recorded when pulp chamber and
root canal were not discernible. A retrospective diagnosis of concussion was made from
patient's history of trauma to the tooth without abnormal loosening, while subluxation
was made from patient's history of trauma to the tooth with abnormal loosening.
66. Results
67. Of the 168 traumatized discoloured anterior teeth, 47.6% and 31.6% had partial and total
obliteration of the pulp canal spaces respectively, 20.8% had pulpal necrosis. Concussion
and subluxation injuries resulted more in obliteration of the pulp canal space, while
fracture of the teeth resulted in more pulpal necrosis (p < 0.001). Injuries sustained during
the 1
st
and 2
nd
decade of life resulted more in obliteration of the pulp canal space, while
injuries sustained in the 3
rd
decade resulted in more pulpal necrosis.
68. Conclusion
69. Calcific metamorphosis developed more in teeth with concussion and subluxation
injuries. Pulpal necrosis occurred more often in traumatized teeth including fractures.
70. Background
71. Epidemiological studies show that about 11.6% to 33.0% of all boys and about 3.6% to
19.3% of all girls suffer dental trauma of varying severity before the age of 12 years [1
3]. The male: female ratio ranged from 1.32.3:1 [13]. In Nigeria, the prevalence of
traumatized anterior teeth in rural population has been reported to be 6.5% [4] while in
the metropolitan population; it is much higher, 14.5% [5]. The number, type and severity
of dental injuries differ according to the age of the patient and the cause of the accident.
Most of the time, these results in coronal fractures that are easily recognizable by both the
patients and their parents, and are also easy to diagnose by the dental practitioner [6].
Moderate injuries to the periodontium such as concussion and subluxation are usually
associated with relatively minor symptoms and hence may go unnoticed by the patient or
the dentist, if consulted [7]. The maxillary central incisors were the most frequently
injured teeth in all studies. While many studies reported the maxillary lateral incisors as
the second most frequently injured teeth that of Forsberg and Tedestam [8] reported the
mandibular central incisors as the second most frequently injured teeth.
72. Concussion may be defined as an injury to the tooth supporting structures without
abnormal loosening or displacement of the tooth but with marked reaction to percussion.
Subluxation is an injury to the tooth supporting structures with abnormal loosening, but
without displacement of the tooth. Patients with these kinds of injuries present years after
a traumatic accident most of the time with a single discoloured tooth. This discolouration
may be the result of obliteration of the pulp canal space, the pulp cavity being filled with
dark tertiary dentine resulting in a tooth with less translucent appearance. Analysis by
means of scanning and transmission electron microscopy shows that the tissues occluding
the pulpal lumen are either dentine like (49%), bone like (19%), or fibrotic (9%) which
could not be correlated with explicit clinical diagnoses [9]. This calcific metamorphosis
may be recognized clinically as early as 3 months after injury [10]. The pulp calcification
and subsequent discolouration increases with time.
73. Approximately 3.8% to 24% of traumatized teeth develop varying degrees of obliteration.
Studies indicate that pulpal necrosis will develop in about 1%16% of these [10]. While
pulpal necrosis only occurs in 3% of teeth subjected to concussion [11]. Following a
severe traumatic injury to permanent immature teeth, the growth of calcified tissue in
pulp canal space may occasionally occur [12]. Also the pulp may become necrotic
leading to the formation of a periapical lesion around a wide-open apex. All these
presents various endodontic challenges to the dentist, in cases of symptomatic teeth with
partial or complete obliteration of the pulp canal space, root canal treatment may become
a difficult or an impossible task respectively [13]. In traumatic teeth with periapical
lesion and open apexes, it will be difficult to get a hermetic apical seal with conventional
root canal treatment.
74. The present study sets out to document the incidence of various post traumatic sequelae
in discoloured anterior teeth among adult Nigerian patients attending the Dental Hospital
of the Obafemi Awolowo University, Ile-Ife, Nigeria.
75. Methods
76. One hundred and sixty eight (168) traumatized discoloured anterior teeth in 165 patients
(95 males and 70 females) were studied. Their ages ranged from 2056 years (mean age
SD 31.3 8.6 years). These included all patients presenting with traumatized
discoloured anterior teeth between August 2003 and July 2005 at the Oral Diagnosis Unit
and the Conservative Clinic of the Dental Hospital, Obafemi Awolowo University Ile-Ife,
Nigeria. The traumatized discoloured teeth may or may not be the cause of presenting
complaint. Discoloured teeth with root canal treatment were excluded from the study, so
also were discoloured teeth with no history of reported injury/trauma.
77. Information extracted from the patients include the history of the discoloured tooth, was
there any previous injury/trauma to the tooth? If yes, how long ago was it? How long
after the injury/trauma was the discolouration first noticed? Is the discolouration
increasing? Has there been any other associated symptom such as pain, swelling, and
discharge from the gum around the tooth (sinus tract)? On examination, any fracture or
loss of tooth structure, intrusion or extrusion was recorded. Results of sensibility test and
radiographic examinations were also recorded. Was there obliteration of the pulp canal
space, and/or apical radiolucency? Was the root formation complete or incomplete?
Partial obliteration was recorded when the pulp chamber or root canal was not discernible
or reduced in size on radiographs, total obliteration was recorded when pulp chamber and
root canal were not discernible. A retrospective diagnosis of concussion was made from
patient's history of trauma to the tooth without abnormal loosening, while subluxation
was made from patient's history of trauma to the tooth with abnormal loosening. The
diagnosis of pulpal status was based on a combination of coronal discolouration,
sensibility test, clinical symptoms, and radiographic evaluation [6].
78. Data were subjected to descriptive and statistical analyses using SPSS for windows
statistical software package Version 11.0. A significance level p < 0.05 was defined as
statistically significant.
79. Results
80. A total of 165 patients (95 male, 70 female) presented with 168 traumatized discoloured
anterior teeth, with a male: female ratio of 1.36:1. All the discoloured teeth included in
this study had histories of some form of traumatic injury leading to fracture of the dental
hard tissues in 38(22.6%) of cases, concussion in 53(31.6%) of cases and subluxation in
77(45.8%) of cases. Causes of injuries were domestic accidents (Impact with person,
impact with objects, fell or pushed), sports, road traffic accidents (RTA), fights (Physical
combat), assault (Abuse), and epileptic seizures (Figure 1). The discolouration resulting
from the traumatic injuries were first noticed 424 months (mean = 13.2 months and
median = 11.0 months) after injury and the discolourations increased with time. The age
of the patients at the time of injury ranged from 7 to 30 years (mean age SD 14.2 6.1
years). About 60.1% of injuries had occurred by age 12. Figure 2 shows the time lapse
between trauma and presentation of discoloured teeth, majority of patients presented 6
10 years after trauma.
81.
82.
83. Figure 1
84. Causes of trauma.
85.
86. Figure 2
87. Time lapse between trauma and presentation of discoloured teeth.
88. Of the 168 traumatized discoloured anterior teeth (167 maxillary incisors; 150 centrals,
17 laterals and 1 mandibular central incisor), 133(79.2%) had obliteration of the pulp
canal spaces; partial obliteration in 80(47.6%) of cases, and total obliteration in
53(31.6%) of cases. Thirty-five (20.8%) had necrosis of the pulp out of which 29 had
closed apexes and 6 had open apexes (Table 1). Fifty-six, (70.0%) and 26.4% of teeth
that had partial and total obliteration of the pulp canal space respectively presented with
pain and also showed pathological periapical changes. Teeth with pulp necrosis presented
with pain in 51.4%, swelling in 34.4%, and sinus tract in 14.3% of cases. Table 2 shows
that concussion and subluxation injuries resulted more in obliteration of the pulp canal
space, while fracture of the teeth resulted in more pulpal necrosis. The differences were
statistically significant (p < 0.001). Partial obliteration of the pulp canal space occurred
more frequently from all the injury types than total obliteration, the differences were not
statistically significant (p > 0.05), Table 2. In 72(42.9%) of cases, the injury to the teeth
was sustained during the first decade of life, while in 32.7% and 24.4% of cases, the
injury occurred during the 2
nd
and 3
rd
decade of life respectively. Obliteration of the pulp
canal space was more frequent in teeth that were traumatized during the 1
st
and 2
nd

decade of life, while pulpal necrosis was more frequent in teeth traumatized during the 3
rd

decade of life. The differences were statistically significant (p < 0.001), Table 3. Pulpal
necrosis occurred more frequently in fractured teeth. Fracture, secondary to road traffic
accident (RTA) resulted to pulpal necrosis more in teeth traumatized during the 3
rd

decade of life.
89. Table 1
90. Incidence of post traumatic sequelae
Post traumatic sequelae No (%)
Partial obliteration 80 (47.6)
Total obliteration 53 (31.6)
Pulp necrosis 35 (20.8)
Total 168 (100.0)
91. Table 2
92. Injury type and post traumatic sequelae
Injury type
A
Partial obliteration No
(%)
B
Total obliteration No
(%)
C
Pulpal necrosis No
(%)
Fracture (n = 38) 8 (21.0) 6 (15.8) 24 (63.2)
Concussion (n =
53)
28 (52.8) 20 (37.7) 5 (9.4)
Subluxation (n =
77)
44 (57.1) 27 (35.1) 6 (7.8)
93. (A+B)vsC:
2
= 53.4, df = 2, p < 0.001; AvsB:
2
= 0.22, df = 2, p = 0.9
94. Table 3
95. Age at time of injury and post traumatic sequelae
Age group
(yrs)
A
Partial obliteration
No (%)
B
Total obliteration No
(%)
C
Pulp necrosis No
(%)
Total No
(%)
1 10 38 (52.8) 29 (40.3) 5 (6.9) 72 (100)
11 20 29 (52.8) 17 (30.9) 9 (16.3) 55 (100)
21 30 13 (31.7) 7 (17.1) 21 (51.2) 41 (100)
96. (A+B)vsC:
2
= 31.57, df = 2, p < 0.001; AvsB:
2
= 1.07, df = 2, p = 0.59
97. Discussion
98. To determine the frequency of calcific metamorphosis in traumatized teeth, it would have
been better to follow-up traumatized teeth for a long period of time. However, from our
experience, response to recall and follow-up visit is very poor. Therefore, it was decided
to look into the incidence of calcific metamorphosis and pulpal necrosis in patients
presenting with discoloured anterior teeth secondary to traumatic injuries. The study was
carried out in Southwestern Nigeria; hence the population studied may not be
representative of the total Nigerian population.
99. Most international surveys reported that males experienced significantly more dental
trauma to the permanent dentition than females [14, 15]. In this study, we got a male:
female ratio of 1.36:1, this falls within the usually quoted range of 1.32.3:1 [13].
However, a lower ratio of 0.9:1.0 has been reported for children less than seven years old
[16]. Domestic accidents accounted for most of the injuries in the present study (37.0%),
this is in agreement with earlier studies [16, 17] that reported accidents at home and
school to account for most injuries to the permanent dentition.
100. In the discoloured traumatized anterior teeth presented in this study, subluxations
were the most frequent type of injury (45.8%), followed by concussions (31.6%) and
fractures (22.6%). These were contrary to the findings of Petti et. al. [18] in which
fractures (enamel, 67%; enamel-dentine, 19.3%) were the most frequent type of injury
followed by concussions (8.3%). Also Rocha and Cardoso [19] reported fractures
(51.4%) to be more frequent than luxation (48.6%). The differences are to be expected
since the present study dealt with discoloured teeth secondary to trauma and not a survey
of all the traumatized anterior teeth. It may be that patients who sustained severe injury to
their teeth resulting in serious fractures had earlier sought treatment, hence the low
frequency of fractures in this study. Because of the difficulty in determining the pulpal
sequelae in traumatized teeth that have already been treated, they were excluded from the
study. Also it is widely accepted that moderate injuries such as concussions and
subluxations most of the time go unnoticed. Patients with such injuries usually presents
later with discoloured teeth.
101. The reactions of the dental pulp to traumatic injuries can be extremely varied.
They ranged from almost immediate pulp death to long-term slow pulp canal
obliterations [20]. In the sequelae of calcific degeneration, the clinical crown frequently
becomes discoloured. In this study, obliteration of the pulp canal space was more
frequent in concussion and subluxation injuries, while pulpal necrosis was more frequent
in fractures. The differences were statistically significant p < 0.001. However, the
differences in the frequency of partial or total obliteration of the pulp canal space were
not statistically significant (p > 0.05) in relation to the injury type. In the present study,
pulpal necrosis occurred in 9.4% of teeth subjected to concussions. This is much higher
than the 3.0% reported by Andreasen and Vestergaard Pedersen [11]. The authors could
not proffer any reason for this. Injuries sustained during the 1
st
and 2
nd
decade of life
resulted more in obliteration of the pulp canal space, while injuries sustained in the 3
rd

decade resulted in more pulpal necrosis. The differences were statistically significant (p <
0.001). It was observed that road traffic accident (RTA) was the major cause of injuries
in the 3
rd
decade of life leading to enamel-dentine fractures.
102. Although prophylactic endodontic treatment in teeth displaying pulp canal
obliteration on a routine basis does not seem justified, it has been reported that the
incidence of pulpal necrosis increases over the course of time [21]. In this study, the
majority (70.0%) of teeth with partial obliteration of the pulp canal space presented with
pain and showed pathologic periapical changes, which may have resulted from pulpal
necrosis. However, this runs contrary to the findings of Jacobsen and Kerekes [22] who
reported normal periapical conditions in all teeth with partial obliteration. Only 26.4% of
teeth with total obliteration presented with pain and showed pathologic periapical
changes. This is in partial agreement with the findings of Jacobsen and Kerekes [22] in
which 21.0% of teeth with total obliteration developed pathologic periapical changes.
From these, teeth with partial obliteration of the pulp canal space are more likely to be
symptomatic than those with total obliteration. Although, an earlier study had suggested
that increase in the amount of calcification might lead to partial or complete radiographic
but not microscopic obliteration of the pulp chamber and root canals [23].
103. Conclusion
104. Calcific metamorphosis developed more in teeth with concussion and subluxation
injuries. Pulpal necrosis occurred more often in traumatized teeth including fractures.
105. Acknowledgements
106. The authors wish to thank all the members of staff working in the Dental
Hospital, Obafemi Awolowo University Ile-Ife Nigeria, for their support during the
collection of data for this study.
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Abstract
Dental trauma is the largest single reason for successful malpractice claims against anaesthetists.
The purpose of this article is to familiarize the anaesthetist with basic tooth anatomy and
pathology and to provide an update on the different types of dental treatment and appliances
which one may encounter in anaesthetic practice. Traumatic fractures to teeth are classified into
six categories; Class I fracture into the enamel layer, Class II fracture into the dentinal
layer, Class III fracture into the pulp of a tooth, Class IV fracture of the root of a tooth,
Class V subluxation of a tooth, and Class VI avulsion of a tooth. Treatment for each class
of fracture is described as well as certain preventative ideas. Some of the more recent
developments in dental therapy such as the butterfly bridge, titanium implants and porcelain
laminate veneers are described. Such developments in their turn have led to new and different
problems. Care must be taken when using the laryngoscope as these teeth may be more easily
fractured or dislodged. Several investigations into malpractice claims found that the oral airway
was responsible for up to 55 per cent of dental complications. Prevention of dental trauma begins
with an understanding of basic tooth anatomy and pathology and a recognition of the different
dental treatments and appliances at the preoperative visit. The value of an appropriate
preoperative dental consultation must not be underestimated.






The most frequent results of trauma to tooth germs are enamel hypoplasia and enamel
hypocalcification. These differing results may be due to the stage of amelogenesis at which
trauma occurs. The cellular and biomolecullar events involved in the genesis of these defects are
poorly understood. We hypothesized that one factor involved is the possibility that relatively
high levels of serum albumin enter the enamel matrix through the damaged enamel organ, and
impair mineralization of the matrix. The present study was undertaken to
immunohistochemically and autoradiographically localize serum albumin in the enamel organs
of rat incisors after trauma was inflicted to the mandibular incisor region of 4-day-old rats.
Hemorrhage was seen surrounding the enamel organ and between the detached secretory-stage
ameloblasts. One day after trauma, the most intense immunohistochemical (IHC) staining for
albumin was localized in the outer layer of the enamel matrix adjacent to the detached secretory-
stage ameloblasts. Albumin was also detected autoradiographically in the secretory-stage
ameloblasts layer and enamel matrix. These findings indicate that serum albumin can leak
between the detached ameloblasts and penetrate the enamel matrix after trauma. Leaked albumin
was still present in the matrix during the maturation stage. Leaked albumin in the developing
enamel could inhibit crystal growth and result in hypocalcification