Accepted: 21 April 2018

DOI: 10.1111/edt.12407

COMPREHENSIVE REVIEW

Prognosis and complications of immature teeth following

lateral luxation: A systematic review

Danielle Clark | Liran Levin

Faculty of Medicine and Dentistry, Division

of Periodontology, University of Alberta,
Edmonton, AB, Canada
Correspondence
Liran Levin, Faculty of Medicine &
Dentistry, School of Dentistry, University of
Alberta, Edmonton Clinic Health Academy,
Edmonton, AB, Canada.
Email: liran@ualberta.ca
Abstract
Background/Aims: Lateral luxation injuries are a type of traumatic dental injury in
which the tooth becomes displaced in the palatal/lingual or labial direction. This in-
jury is common among children and can result in pulp canal obliteration or pulp ne-
crosis. The objective of this systematic review was to gather existing data on lateral
luxation injuries to immature teeth to evaluate their overall prognosis.
Methods: A systematic search was conducted using Medline, Pubmed, Scopus, Lilacs,
EMBASE and Cochrane databases in October 2017. Reference lists were also hand-­
searched to identify additional literature. Prospective and retrospective observa-
tional studies were included. A total of 502 articles were screened and six articles
were included in the study.
Results: Pulp canal obliteration was the most frequent complication of immature
teeth with lateral luxation (31.3%). This was followed by pulp necrosis (17.5%), inflam-
matory resorption (5.7%), and surface resorption (3.2%). Due to the heterogeneity of
the studies, a meta-­analysis was not attempted. There was great variation in the re-
ported outcomes among the studies.
Conclusion: Accurate prognosis evaluation of traumatic dental injuries is difficult due
to the nature of current studies being retrospective or prospective cohort studies.
Lateral luxation is a common traumatic dental injury and has life-­long concerns for a
patient. It is important for future studies to report on the same outcomes to increase
the quality of evidence regarding prognosis and treatment interventions, not only for
lateral luxation injuries, but for all traumatic dental injuries.

KEYWORDS
dental trauma, obliteration, pulp necrosis, replacement resorption, tooth loss

1 |  BAC KG RO U N D
Traumatic dental injuries essentially involve different forms of tooth
damage. Avulsion, intrusion, extrusion, and luxation are some possi-
ble cases of dental trauma. Most of these injuries are common in a
younger population, specifically, lateral luxation injuries.1 Luxation
injuries are one of the most prevalent traumatic dental injuries
in the primary dentition.1 These injuries were first described by
Andreasen. 2 They involve a displaced tooth in the palatal/lingual or
labial direction.1,2 The alveolar process is fractured due to the in-
jury and as a result, the tooth becomes immobile.1,2 Percussion tests
can result in an ankylotic sound and sensibility tests often provide
negative results.1 Lateral luxation injuries often present a widened
periodontal ligament space that can be identified from eccentric or
occlusal radiographs.1
The epidemiology of lateral luxation injuries is well studied.
Dental trauma injuries in the primary dentition often occur within
1-­4 years of age. 3–6 Males are also more likely to experience

Dental Traumatology. 2018;34:215–220. wileyonlinelibrary.com/journal/edt   © 2018 John Wiley & Sons A/S. |  215
Published by John Wiley & Sons Ltd
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216       CLARK and LEVIN
dental trauma than females and lateral luxation is no excep-
3–5
tion. Lateral luxation injuries are one of the most common
dental trauma injuries experienced. The current literature re-
ports that lateral luxation makes up 29.5%-­57% of all dental inju-
ries. 3,6–8 Unfortunately, even if laterally luxated teeth are treated
with repositioning and splinting, they can encounter long-­term
complications such as pulp necrosis with infection and periapical
inflammation.
The International Association for Dental Traumatology has pub-
1
lished guidelines for the treatment of dental trauma injuries. The
guidelines include treatment options for teeth with lateral luxation.
Currently, if a patient presents with lateral luxation, the clinician
is responsible for repositioning the tooth to its original location.1
The tooth should then be stabilized using a splint for 4 weeks and
the condition of the tooth should be monitored.1 In the event that
the pulp becomes necrotic and infected, and root canal treatment
should be performed to prevent external inflammatory resorption.1
Although there are published guidelines for the treatment of lateral
luxation injuries, there is little research identifying the prognosis of
these teeth. Lateral luxation injuries often occur in children and it
is optimal for treated teeth to remain functioning in the dentition
throughout their life.
The aim of this study was to analyze the following PICOS ques-
tion: What is the prognosis of immature teeth following lateral luxa-
tion injuries in the general population?
2 |  M E TH O DS
The present systematic review was conducted according to the
guidelines in the Cochrane Handbook for Systematic Reviews
of Interventions.9 PICOS guidelines were used to structure the
main question and the PRISMA checklist and flowchart were
10
used to guide the review process. The Newcastle Ottawa Scale
was used to assess risk of bias for the non-­randomized control
studies.11
This systematic review included prospective and retrospec-
tive observational studies. These studies were included because
randomized control trials are not available nor feasible or ethical
for dental trauma research. Case series, case reports, and reviews
were excluded. Due to limited resources, the search was restricted
to English language only. There was no restriction on date of pub-
lication or follow-­up time. Studies evaluating the impact of lateral
luxation injuries sustained in primary teeth on their permanent
successors were excluded. If studies assessed teeth with multiple
injuries such as concomitant crown fractures, they were excluded.
Only studies assessing prognosis of lateral luxation injuries were
included.
The included studies were restricted to human subjects with
no restrictions on age/gender/sample size. Although the objective
of the study was to assess immature teeth, age restriction was not
placed during the search to ensure the inclusion of all appropriate
studies.
There are two possible types of intervention for lateral luxation
injuries. The first is repositioning and splinting the tooth and the sec-
ond includes the former with the addition of root canal treatment.
All reported outcomes were considered. Only outcomes re-
ported by two or more studies were assessed statistically. These
outcomes included pulp canal obliteration, pulp necrosis, surface
resorption, inflammatory resorption, replacement resorption, and
internal resorption. An electronic search was done in the following
databases: Medline, Pubmed, Embase, Scopus, Lilacs, and Cochrane
Library in October 2017. Additional studies were included by hand-­
searching through reference lists as well as through correspondence
(experts, dental organizations).
The search in MEDLINE was entered as demonstrated in Table 1.
This search was modified for the other databases accordingly.
The search resulted in a total of 502 articles. After dupli-
cates were removed, 240 remained. The titles and abstracts were
screened and irrelevant studies were excluded (n = 217). A total of
25 articles were downloaded and assessed for eligibility (Figure 1).
Downloaded articles were excluded if lateral luxation evaluation
was not specified, the same cohort of patients was used for another
study, there was no follow-­up period, or if multiple injuries were sus-
tained to the tooth. Three studies were excluded because the mea-
sured outcomes did not differentiate between mature and immature
teeth.12–14 After screening, a total of six articles were chosen for
quality assessment and data extraction. Data extracted from the six
articles included are as follows: authors, publication year, study de-
sign, sample size, treatment, follow-­up period, and the assessed out-
comes. Quality was assessed using the Newcastle-­Ottawa Scale.11
3 | R E S U LT S
Six studies were included for data analysis. Characteristics of the
included studies are shown in Table 2 and the quality assessment of
studies using the Newcastle-­Ottawa Scale in Table 3. The diagnostic
criteria were not well described within the included studies. As a
result, the heterogeneity of the study results could not be statisti-
cally assessed, and a meta-­analysis was not attempted. Outcomes
TA B L E   1   Search conducted in medline
# Searches Results
1 (Tooth OR Teeth OR Dental).mp. [mp=title, 522 830
abstract, original title, name of substance
word, subject heading word, protocol
supplementary substance word, rare disease
supplementary concept word, unique
identifier, synonyms]
2 (Luxation OR Displace* or Injur* OR 299 289
Dislodge*).m_titl.
3 (Outcome OR Follow-­up OR Survival OR 987 537
Complication* OR Success OR Prognosis OR
Consequence OR Evaluation).m_titl.
4 1 AND 2 AND 3 198
CLARK and LEVIN |
      217

Identification

Average length of F/U:

Retrospective Cohort
Medline: 198

Repositioning/No
Soporowski et al,
Pubmed: 89

treatment
4.3 years
Embase: 185

175/307
(1994) 8
Cochrane Library: 30

n/a
Other: (hand searched):
9
Total: 502

Hospital, Rigshospitalet,
Copenhagen University
Lauridsen et al, (2017)18

Department of Oral and

Maxillofacial Surgery,
Retrospective Cohort
Records screen after

F/U up to 3 years
duplicates removed

Minimum: 1 year
n = 240

No treatment
Denmark
Records excluded

80/357
based on
title/abstract
n = 217

Manual Reduction and

Full text articles

Ferrazzini Pozzi et al,

Prospective Cohort
assessed

Minimum: 4 years
n = 25

Splinting
(2008)17

3/66
Articles included

n/a
Full text articles
excluded n=6
No follow up/follow up
not specific for laterally

Faculty Hospital, Pilsen,

Manual Reduction and

luxated teeth n = 6
Hecova et al, (2010)16

Retrospective Cohort
Luxation injury type

Minimum: 5 years
not specified/Injury Czech Republic
not lateral luxation n = 7

Splinting
Lateral luxation injury

66/889
combined with other
injury n = 2
No differentiation
between immature and
Campus, Haifa, Israel
Retrospective Cohort

mature root
Median: 2.99 years
development n = 3
Range: 1-­12 years
Rambam Medical
Lin et al, (2016)15

Same cohort of
patients studies n = 1
51/287

Total = 19
n/a

F I G U R E   1   Flow diagram of the systematic search

Range:10.8 months-­22 years
Hospital, Rigshospitalet,
TA B L E   2   Characteristics of included studies

Copenhagen University
Department of Oral and

that were assessed by two or more studies were selected for data
Hermann et al, (2012)19

Maxillofacial Surgery,

Manual Reduction and

Retrospective Cohort

analysis. These outcomes included pulp canal obliteration, pulp

Median:1.3 years

necrosis, internal root resorption, external surface resorption, ex-

ternal inflammatory resorption, and external replacement resorp-
Denmark

Splinting

tion (Table 4). Pulp canal obliteration was reported in five of the six
48/261

studies. The combined data from these studies show that 31.3% of
immature teeth presented with pulp canal obliteration following lat-
eral luxation injuries.8,15–18 Pulp necrosis was also reported in five
Sample Size (Lateral

Teeth/Total Teeth)
Luxated Immature

Follow Up (years)

of the six studies. The prevalence of pulp necrosis in laterally lux-

ated immature teeth was 17.5%.8,15,16,18,19 Lin et al and Hevoca et al
Study Design

Treatment

reported internal root resorption and it was estimated to affect only

Location

0.9% of teeth.15,16 Approximately, 3.2% of immature teeth presented

with external surface resorption while 5.7% developed external
TA B L E   3   Risk of bias assessment
|

Selection Comparability Outcome

218      

Demonstration
that the Outcome Comparability of Adequate
Representative of Selection of the of Interest was not Cohorts based on Follow-­Up for Adequacy of
Authors (year) the Exposed Non-­E xposed Ascertainment of Present at the study design or Assessment of Outcomes to follow-­up of
(Reference) Cohort Cohort Exposure start of the study analysis Outcome Occur Cohorts

Hermann et al, * Not Applicable * * Not Applicable * * *

(2012)19
Lin et al, (2016)15 * Not Applicable * * Not Applicable * * *
Hecova et al, * Not Applicable * * Not Applicable * * *
(2010)16
Ferrazzini Pozzi * Not Applicable * Not Applicable * *
et al, (2008)17
Lauridsen et al, * Not Applicable * * Not Applicable * * *
(2017)18
Soporowski et al, * Not Applicable * * Not Applicable * * *
(1994) 8

TA B L E   4   Pooled reports of complications of laterally luxated immature teeth

Internal root
Study Pulp canal obliteration Pulp necrosis resorption Surface resorption Inflammatory resorption Replacement resorption

Hermann et al n/a 1/48 n/a 1/48 1/48 0/48

Lin et al 0/51 6/51 0/51 n/a 2/51 0/51
Hecova et al 23/66 9/66 1/66 1/66 3/66 5/66
Ferrazzini Pozzi et al 2/3 n/a n/a n/a n/a 0/3
Lauridsen et al 132/331 62/331 n/a 12/331 22/331 2/331
Soporowski et al 9/80 23/80 n/a n/a n/a n/a
Pooled Incidence n=166/531=31.3% n=101/576=17.5% n=1/117=0.9% n=14/445=3.2% n=28/496=5.7% n=7/499=1.4%
CLARK and LEVIN
CLARK and LEVIN
inflammatory resorption. Finally, an estimated 1.4% of immature
teeth developed external replacement resorption.
4 | D I S CU S S I O N
As lateral luxation injuries are a frequent form of dental trauma,
it is important to make informed evidence-­based treatment deci-
sions when treating and evaluating the prognosis of traumatized
teeth. Dental trauma injuries occur frequently in young patients and
often, complete root development has not been reached. Root de-
velopment and age have been previously reported to be the most
influential factors for pulp necrosis in traumatized teeth. 20 Another
influential factor for pulp necrosis is the extent by which the treat-
ment of the injury was delayed by the patient. 21–23 This factor was
not accounted for in the included studies and is a confounding vari-
able that may have a significant influence on the results.
Overall, pulp canal obliteration was the most frequently reported
complication of lateral luxation injuries. Although less common, cli-
nicians should also monitor for other complications such as exter-
nal inflammatory resorption and external replacement resorption.
Therefore, patients need to understand the importance of maintain-
ing regular follow-­up appointments. Unfortunately, due to the na-
ture of dental trauma, it is difficult to conduct randomized controlled
trials to determine the efficacy of different treatments and to prop-
erly evaluate prognosis. In this systematic review, there were only
six outcomes in common among the included studies. This finding
is better discussed in the systematic review by Sharif et al which re-
ported that dental trauma often includes different outcomes which
results in major heterogeneity among studies. 24
A consequence of
this is the inability to conduct a meta-­analysis. This is particularly
important in the field of dental trauma where RCTs are not feasible.
This will hopefully change in the near future with the introduction of
a core outcome set. 25 The core outcome set was developed by an ex-
pert working group comprised of specialists in oral and maxillofacial
surgery, emergency dentistry, endodontics, restorative dentistry,
pediatrics, periodontology, orthodontics, and general dentistry. The
group assessed possible outcomes and agreed on the inclusion of six
core outcomes (also considered generic outcomes). They include in-
jury activity, physical consequence of disease, functional status, so-
cial outcomes and quality of life, side effects of therapy, and health
resource utilization. Another outcome specific to the type of dental
injury was also introduced. In the case of lateral luxation, infraoc-
clusion should be noted and for primary teeth, realignment and the
impact on the permanent predecessor should be assessed. These
outcomes are to be assessed at the follow-­up intervals as recom-
mended by the IADT.1 A description of the measurement methods
is also provided in the core outcome set. 25 The primary purpose of
the core outcome set is to help guide reporting of traumatic dental
injuries to facilitate more accurate evidence regarding the outcomes
of these injuries. This will eventually lead to more accurate prognosis
and treatment evaluation for traumatic dental injuries.
|
      219
Randomized controlled trials were not available due to the nature
of this research. Observational studies were included and therefore
there is potential for selection bias and confounding variables which
may have influenced reported outcomes. There is also the possibility
for detection bias as outcome measurements were not standardized.
5 | CO N C LU S I O N
This systematic review highlights the prevalence of complications
following lateral luxation injuries in immature teeth. Pulp canal oblit-
eration was the most frequent complication and emphasizes the
need for proper follow-­up of lateral luxation injuries. Nonetheless,
the results of this systematic review are based on retrospective co-
hort studies which present some bias. Although the results have lim-
itations, this review emphasizes the importance for researchers to
utilize the core outcome set for reporting traumatic dental injuries.
C O N FL I C T O F I N T E R E S T
The authors confirm that they have no conflict of interest.
ORCID
Liran Levin  http://orcid.org/0000-0002-8123-7936
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How to cite this article: Clark D, Levin L. Prognosis and
complications of immature teeth following lateral luxation: A
systematic review. Dent Traumatol. 2018;34:215–220. https://
doi.org/10.1111/edt.12407