Prognosis of luxated permanent teeth - the development of pulp necrosis

Atidreasen EM, Vestergaard Pedersen B. Prognosis of luxated permanent teeth - tbe development of pulp necrosis. Endod lDent Traumatol 1985; 1: 207-220. Abstract - A population of 400 patients, eomprising 637 luxated p e r m a n e n t teeth was studied prospeetively with respect to the development of pulp necrosis after luxation injuries. The patients w e r e treated for traumatic dental injuries over a period of 10 years. While initial treatment was provided according to established treattnent guidelines by the attending oral surgeoti at the emergency room, foUow-tip examination and treatment was prov i d e d by one oral surgeon. It ap]3eared th;tt pulp necrosis occtn-red s o o n after injury, within 3 tnonths after conctission, wilhin (he 1st yr after subluxation and extrusion, and might be diagnosed u p to 2 yr after lateral- and intrtisive ltixatioti. While tnany factors, when considered one at a tintc, were Ibund to have a signifteant or nearly significant ellect on the devclo]imcnt o( ptilp necrosis (i.e. type of injtn-y, age of jxttient, stage of root developm e n t , degree of dislocation, reducli(3n/rc|3ositioning j^roccdurc, t y p e of fixation, restorations in place at the lime of injtiry), a mullivariate regression analysis revealed lluil when ihe type of injury (diagnosis) and stage of f o o t development were taken i n t o account, (he elfecl of other factors was no longer significant. "riie risk of pulp neerosis increased witfi the extent of injury, i.e. concussion and subluxation represented the least risk, followed i n ascetiding order by extrusive-, lateral-, and ititrusive luxa t i o n . Moreover, teeth wilfi (om|)letcd root formation detnons t r a t e d a greater risk of pul]5 necrosis than teeth witfi iticotnplete r o o t fbrmation. No treattnent effect could be demonstrated. However, as treatment was perfortned accotding to established guidelines, which might introduce bias, it would appear justifted to c o n d u c t randomized elinieal sttidies in oider to determine the v a l u e of different forms of treatment (e.g. reduction and ftxation o f luxated teeth) to improve tlie prognosis with respect to the development of pulp necrosis after injury. In conclusion, the m a j o r faetors influencing dcveloi^ment of pul]3 necrosis after hixa t i o n injuries appear to be the extent of the initial injury to the p u l p and periodontium, as reflected by the type of luxation, a n d the repair potential of the injtu'ed tooth, as reflected by the s t a g e of root dcvefoi^ment.

Frances iVI. Andreasen* and Bo Vestergaard Pedersen**

'Department of Oral Medicine and Oral Surgery, University Hospital (Rigshospitalet), and Department of Pedodontics, Royal Denial College, Copenhagen. "Statistical Research Unit, Copenhagen University and the Danish Breast Cancer Cooperative Group, Finsen Institute, Copenhagen, Denmark

Key words: luxation injuries, prognosis, pulp necrosis, root development, proportional hazards regression model, grouped survival data. R M. Andreasen, nD.S., Department of Oral Medicine and Oral Surgery, University Hospifal (Rigshospitalet), Tagensvej 18, DK 2200 Copenhagen N, Denmark. Accepted for publication 13 May 1985.

Desj^ite many chnical and experinienlal sltidies, the etiology of pulp tiecrosis after luxation injuries is still uncertain (1 14). The general outcome of these investigations has been the idetitiflcation of clinical factors wliich, (o a greater or lesser degree, were f o u n d to \)c associated with the developtnent of pttlp

neci'osis after injury. These factors include: age of the patient (1, 3, 8, 9), stage of root development (1, 3, 5 12, 27), type of luxation injury (3, 6, 8, 9, 11, 12, 27), mobility of the injured tooth at the time ofinjtiry (1, 2, 6, 8, 13), degree of dislocation (14), initial positive reaction to pulp testing (1, 5, 6, 13),

207

Andreasen and Pedersen

tenderness to percussion at the time of injury (13, 15), the type of reduction procedure (2, 16), fixation period (2), and delayed initial treatment (1, 5, 6, 8). These results imply a rather complex etiology of pulp neerosis after luxation injuries. However, in many of these studies, only the Jrequency of pulp necrosis in relation to one factor at a time was studied. Sueh analyses neglect the time from injury to occurrence of pulp necrosis and cannot account for the possible close associations between factors studied, sueh as between age and root development or mobility and displacement of an injured tooth and the type of luxation. A multivariate analysis is required to identify the smallest set of factors whicfi contains the greatest amount of prognostie information with respeet to development of pulp necrosis after luxation injuries. It is therefore the aim of the present investigation to answer the following questions using a population of patients whieh has been uniformly treated for luxation injuries to the permanent dentition and followed prospeetively for up to 10 yr: 1. Which types of luxation injuries are followed l)y pulp neerosis and to what extent? 2. What is the chronologieal relationship between type of luxation injury and the diagnosis of pulp necrosis? 3. Wfiich factors associated with injury or subsequent treatment determine the development of pulp necrosis alter ltjxation injuries?
Material and methods Material

Table 1. Distribution of luxation injuries according to type of luxafion and stage of root development. Numbers In parentheses indicate fhe number of teeth which developed pulp necrosis after injury. Luxation type Concussion Subluxafion Extrusion Lateral luxafion Intrusion Total Open apex 58 (0) 130 (0) 33 (3) 34(3) 24(15) 279 (21) Closed apex 120 (5) 93 (14) 20 (11) 88 (68) 37 (37) 358 (135) Total 178(5) 223 (14) 53 (14) 122 (71) 61 (52) 637 (156)

ty measured electromctrically. Pulp necrosis was occasionally associated with spontaneous pain or tenderness to percussion; but most cases were completely asymptomatic. In the present investigation, loss of electrometrie sensibility and at least one other objective sign was considered necessary before tbe diagnosis "pulp necrosis" was made. Table 2 presents a seleetion of variables registered in the present investigation, their distribution in tbe 5 luxation categories and the frec[ueiicy of pulp necrosis in each group irrespective of observation period. A more detailed discussion of these variables and their scoring were presented in a previous paper (17). A number of variables not shown in Table 2 were studied but found to have no effect on the development of pulp necrosis. These include: jarefixation period, percussion (ankylosis) tone at the time of injury, sensitivity to eold air, constant |3ain and loss of marginal bone support (i.e. |:)ci iodontal involvement) at the time of injury.
Statistical methods

'fhe material eomprises 400 patients with 637 luxated teeth and 414 non-injured (control) teeth selected from 3260 referred to and treated fbr luxation injuries at the Department of Oral Medicine and Oral Surgery, University Hospital, Copenhagen. Details concerning selection of patient material, diagnostic criteria for luxation injuries and treatment l^rocedures have been described elsewhere (17). Only teeth which fulOllcd the criteria for luxation injuries (18) were admitted to the study; that is, concussion, subluxation, extrtisive luxation, lateral luxation and intrusion. lable 1 presents the distribution of teeth according to type of luxation injury and stage of root formation. 'I'he stage of root development at the time oi injury corresponds to the classification system established by Moorrees et al. (19). In the present investigation, ineomplete root formation was defined as one-, two-, three- or four-quarters' root length and open- to half-open apex; comjiletc root formation was full root length and closed apex. Criteria for the diagnosis of pulp neerosis were the following (18): grey color changes in the crown, periapical radiolueency, and loss of pulpal sensibih208

Eor each luxation category the possible elfect of a number of variables was reviewed initially by simple tabulation of the frequency of pulp necrosis irrespective of observation period using informal %' or Eisher's exact test for comparison between groups. In the subsequent analysis, the time until tbe diagnosis of pulp necrosis was taken into account. As the development of pulp necrosis is usually asymptomatic, it could only be recorded at the predetermined fbllow-up visits; the data thus took the form of grouped survival data. Univariate- and multivariate regression analysis of such data can be adequately performed by the computer program CENSTAT, as described in the statistical a]5penclix. Reductions from one model to a less eomplex one were tested by the likelihood ratio test, by which the dilTert^nce in deviances given by GENS'lAT were eomjjared to a ^c^ distribution with degrees ol freedom equal to the difference in degrees of freedom between the two models. The elinieal eourse for the individual tooth was

Pulp necrosis after luxation injuries in permanent dentition

Table 2. Distribution of feefh and relative frequency of pulp necrosis according fo luxation category and selected variables. Luxafion cafegory: Concussion Subluxation Variable Crown tracfure Scoring None Infracfion Uncomplicated Laferal luxation n % 115 56 100 11 29 11 84 58 58 57 82 -

n
145

%
3

n
214 9

%
6

Extrusion % n 50 26 33 25 75 67 25

Intrusion %

24

33 24 72
56

3 .5 8
3

22 30 24 5

3
18 24 8

7
18 28 44 32 50

1
36

79 100
89 83 71 100 100 90 81 83 93

Age

g 7 yr 8-11 yr 12-19 yr >20yr

Male Female 11,21

81
92 33 17 83 140 136 55 26 6

12
24 13 12 29 32 46

26
68

3
12

Sex
FDI code

110
90 81 5

3
4

7
7

41
44

27
30

72
100

12,22
31,41 32,42 Stage of roof formation

2
2 18 31 7 120 18 160 24

1 _ 4 6 3

5
4 15 8 6 8 4 10

4
4 1 2 15 15 1 20 4 49 6 24 19 4 14 17 22 48

25 20 55 50 24 33 13 37 50 50 18 18 27 20 24 57

17
5

15

1/4 2/4 3/4

4/4. open 4/4, half 4/4, closed

2
17 62 37 12 93

7 12 12 3 88 18 104 19 58 34 11 47 28 47 97 25 56 33

14 8 33 11 83 54

6 16

2
37 11 50 5 19 26 11 17 18 13 13 45 16 18 5 38 10

83 50 100 100 100 82 100 79 92 73 88 78 11 100 84 88 89 100 82 90

Previous restoration No. of injured teefh in same dental arch Year of injury

Yes

12
211 40 102 59 22 78

No
1 2 3 4-6 1966-71 1972-74
1975-77

61
62 31 79 45 54 147 31

3
3 3 4

37 53
74 73 62 39 66 60 52 54 61 64 100 56 64 60 58

5
5 6 8 6 9

2
2 3 3

53
92 189 34

1978-81
Oral surgeon Experienced

+ Degree of repositioning Reducfion procedure Complete Incomplete None Surgical Manual Orthodontic None
CONCISE* SCUTAN" Cap- or

5
37 7 9 44

178

223

11 30
11 20 36

33
1 88 33 25 26

13
26 12 5 5 11

92
88 67 80 100 91 76

178 16 11

Type of fixation

3 _ -

223 16 23

6 19 4

9 15 11

acrylic splinf Suture or no splinf Orfhodonfic bands UNKNOWN Antibiotic

133

4 _ _ 3

165

13

33

64

21

18
13 165

19
25 198 156 40

5
8 6 6 3

19
4 49

32 25
27 50 11 25

38
11 111 41 46 18 15 2

53
55 59

17
2 20 41

94
50 85 85 83 67 100

Yes
No
None

therapy
Degree of loosening

178

2
9 8 33 1

73
63 33

46
3 1

1
2

3
UNKNOWN

27

11

30 -

33
50

5
6

100
100

209

Andreasen and Pedersen

Table 2. Contd. Luxafion cafegory: Subluxafion Concussion n % n % 178 3 191 7 Lateral luxation % n 99 15 8 59 53 63

Variable Tenderness fo percussion Reaction fo pulp fesfing Pain on occlusion

Scoring Yes No UNKNOWN Positive Negative UNKNOWN Yes No UNKNOWN g 3 wk 3-4 wk

Extrusion % n 46 28

Intrusion % 79

14

28
4

6
1

17 10 33 14 42 18 20

36
11

86
91

136
35

14 10 2 _ 4 3 (5)

93
107 23 33 187 3 21 14 10 13 165 223 (14)

2
11 18 4 14 .10 8 5 6

10
36

8
93 21 59 63 31 16 19 24 32 122 (71)

25
61 57 63 54 42

1
41 19 11 48

100
85 84 73 90

7
20 158 14

7
19 33 1 15 8 14 10 6 53 (14)

2
2 11 24 21 3 61 (52)

50
100 82 96 76 67 85

Fixation period

5
7

13
50 20 17 26

63
68 58 66 58

4-6 wk >6 wk
None UNKNOWN Total (no. puip necrosis)

22
130 178

assumed to be inde|x'ndent ol that of adjacent teeth. I his assumption was investigated by studying the eflect of the number of injured teeth in the same dental areh.

Results Frequency of pulp necrosis

Table 3 presents a list of the e(MTipli( ations studied and their frequency in the .5 luxation categories in the present material. As pulp necrosis was the most frequent complication, it was analyzed first. Other Grouped survival data for pulp necrosis complications, including root resorption, pulp canal obliteration and marginal periodontal breakdown lMg. I shows the distribution of observation times were also registered. Prognosis and definitions of from the time of injury to cither the devel()])ment these will be the subject of separate studies. of |:)ulp neerosis or the last follow-ti]i examination ]:)rior to termination of data cx)llection. Pi\\p necrosis Table 2 presents a detailed survey of frec|ueney tended to occur relatively soon after injury, if it of ptilp necrosis by luxation category, irrespective occtured at all; most instances were diagnosed of observation ]:)eriocl in relation to the variables within 3 months after trauma. However, a few cases studied. Only a few variables seemed to have a were diagnosed as late as 1 yr after subluxation and strong effect on the occurrence oi |3ulp necrosis; more speeifically, patient age and stage of root forma lion, extrusion; and up to 2 yr after lateral luxation and intrusion. Etnlher it can be seen tha( observation both indicators of the individual tooth's stage of times were concentrated around the predefined foldevelopment. The severity of the injury, as reflected low-u]3 sehedule: 3 wk, G wk, 3 months, 1 yr, 5 yr. by the number of injured teeth in the same dental arch or by infraetioit did not a|Dpeai- to allect prognosis A slight concentration of observations eould also be noted at approximately (3 months, 2 yr and 3 yr. except after lateral luxation, where all teeth with This was due to the follow-u]3 schedule used for infraction developed ijulj) neerosis and where the replantations and root (racttues at which time many frequency of pulp necrosis appeared to increase with luxated teeth were examined. A 10-yr follow-up was the number of injured teeth in the same dental arch. originally intended. However, as no instance of ]3ulp There was an increased occurrence of pulp necrosis in teeth with restorations at the time of injury in all necrosis was seen at the 10-yr follow-up examinaticjn, this interval was not included in the statistiluxation groups. Apart from these, no other factors cal analysis. appeared to have a notieeable relationship to prog210

nosis. Thus, Ireatmenl, described by the variables degree of repositioning, redtution procedure, type of fixation and antibiotic th<~rapy did not seem to have an elfect on |)ulp healing after trauma. To verify that teeth in the control group were in fact non-injured, the frequeney of pulp necrosis in that grou|5 was also studied. Two out of 4H- teetb in the control group developed pulp necrosis duringthe observation period; secondary causes for pulp necrosis (e.g. caries, a second trauma) w(-re not found in these 2 cases.

Pulp necrosis atter luxation injuries in permanent dentition

Table 3. Oisfribufion of complications after luxafion injuries in fhe permanenf denfifion according fo fype of luxafion injury. Type of luxafion: Concus-

sion
Complicafion Pulp necrosis Roof resorption Ankylosis Inflammatory resorpfion Ankylosis-i-Inflammafory resorpfion Surface resorpfion Infernal resorpfion Apical radiolucency Marginal breakdown Parfial pulp obliteration Tofal pulp obliferafion Arresfed roof developmenf Disturbed roof developmenf Gingival refraction * % of fhe given luxation category. (n=178) 5(3)9(5) 0(0) 0(0) 0(0) 8(4) 1 (0) 3(2) 0(0) 9(5) 0(0) 0(0) 0(0) 2(1)

Subluxafion

(n=223)
14(6)
4(2)

Exfrusion (n=53) 14(26) 5(9) 0(0) 3(6) 0(0) 3(6) 1 (2) 11 (21) 3(6) 24 (45) 2(4) 3(6) 2(4) 2(4)

Laferal luxation (n=122) 71 (58) 33 (27) 1 (1) 4(3) 0(0) 32 (26) 1 (1) 45 (37)

Infrusion (n=61) 52 (85) 40 (66)

Total (n = 637) 156 (24) 91 (14) 16(2) 31 (5) 1 (0) 62 (10) 4(1) 111 (17) 34(5) 96(15) 9(1)

0(0) 1 (0) 0(0) 4(2) 0(0) 11 (5) 3(1) 23 (10) 1 (0) 1 (0) 3(1) 4(2)

15(24)
23 (38) 1 (2) 15(24) 1 (2) 41 (67) 19 (31) 6(10) 2(3) 10 (16) 4(6) 7(11)

9(7)
34 (28) 4(3) 6(5) 7(6) 9(7)

20(3) 16(2) 24(4)

As exact scheduling of patients at 3 wk, t) wk, etc. was impossible, actual fbllow-iii^ times had to be grouped. Observations in the intervals 0 1 month, 1-2 months, 2-5 months, 5-18 months, 18 70 months were acce|5ted as corrcspcjiiding to each of ihe predetermined follc)w-ti|3 times. This ajjplied except for acttial fbllovv-ti|3 times with or withotil pulp necrosis which could not stir\ i\e fhe fbllow-up time in question; such observations were excluded from analysis of that particulai' interval. Thus, a tooth last seen 3 yr after injury is registered as having survived the 1 yr follow-up, but can contribute to 5 yr survival onlv if it entered the study early enough t o have a potential 5 yr IOIIOW-UJD. Using these conventions, life tabfe estimates fbr t h e overall survival without pulp necrosis for teeth in the 5 Itixation categories were calctilated (Eig. 2). Large diirerences in performance are apparent. Urtivariate analysis Table 4 presents the results of the uui\ ariate group e d survival analysis of the elfect of variables investig-ated. The columns in 'Jable 4 contain 0, the estimated regression cocllicient of the variable in question. Eor a qualitative variable, a negative value of 0 implies an improved prognosis, while a jjositive 3 implies a worscncxl ]jrc)gnosis fbr the gi\'en group. F o r a quanlitalive variable (e.g. age) a positive (5 indicates a worsened prognosis with iiu-rcasing vahie o f the given variable. The p values indicate the level o f significance of the effeet as determined by the likelihood ratio test. The fbllowiiig effecUs were observed in the univar i a t e analysis. Ccjiicomitant infraction tended to have a negative effect on pi'ognosis; but was not significant cxc:ept

after lateral luxation (p = 0.02). Prcjgnosis for all luxation t)pes except perhaps concussion was significantly worsened with increasing age of the patient at the time of injury (p = 0.1 7, 0.0002, 0.0002, 0.006, O.OO-l fbr concussion, subluxation, extrusion, lateral luxation and intrusion, respectix'ely). The missing eflect after concussion was presumably dtie to the very few instances of ])tilp neerosis obscr\ed in this Itixation category. There was a trend towards a poorer prognosis if the injured teeth contained restorations at the time of injury (p = 0.05 and 0.07 for laferal luxation and intrusion, respectively). Completed root formation very clearly worsened the prognosis after injury. Eor eoneussion and subluxation, all teeth whieh de\eloped pulp necrosis had com]Dletely developed roots; the univariate survival analysis could thus not be used in these luxation eategories. Eor extrusive-, lateral- and intrusi\ e luxatic:>n, the effect was highly significant, p = 0.0002, < 10 '', < 10"'', respecti\'ely. There was a tendency towards a worsened prognosis as the number of injured teeth in the same dental arch increased (p = 0.0004 for lateral luxation). In order to determine whether prognosis varied throughotit the period studied, the year of injtii')' was considered. A somewhat belter prognosis was observed in teeth admitted fo the sttidy in the years 1975-1977, significant only for lateral luxation (p = 0.01, d f = 2 ) . ' Efibcts from (he remaining variables were sporadic. However, after subhixation and lateral luxation, a significantly better prognosis was seen when teeth reactedposilively to electrometrie ptilp testing at the time of injury than if they did not (p = 0.01 aiul 0.04, respectively). Of the subjective symptoms registered at the time of injury (pain from occlusion, sensitivity to cold 211

Andreasen and Pedersen

PULP SURVIVAL AFTER LUXATION INJURIES. Total material. a e concussjon subluxation

extrusion

laL lux.

intrusion

No. at risk during interval;

173

subluxation

o
53

212

73

Fig. t. Distribulioii ol observation times Irom injury to cither the dcvelo])rn(Mil of pulp necrosis (solid, black columns) or (he fast fbllow-iip cxamiiKilion |)rior lo lerniinalion ol data collection (elonijjated 1 's). i'.acii li( on the Y axis niduales 5 instances ol eilher pulp necrosis or survixal vvilhoul pnlp necrosis.

extnjsion laL lux. intnjsion

_L22_

1 13

74

C)1

air, constant pain), only pain from occlusion seemed to be aecompanied by a worsened i^rognosis, significant for subluxafion and extrusion (]3 = 0.01, 0.05, respectively).
Multivariale analysis

Fig. 2. Life lalile esliniales olsnivival wilhoul pnlp neerosis of leeth in (he .') luxalion categories.

The following is a review of the mtiltivariate anttlysis for each luxation category based on simultaneous inelusion of thcise variables fbund to be of interest in the univariate analysis described above. According to the univariate analysis (Table 4), the two most important variables with respect to the development C I |3ulp necrosis were age and root D formation. These two variables, however, were closely associated. It was only in the group 8-1 1 yr of age (Table 2) that there were teeth with both complete and incomplete root formation. The group ^ 7 yr contained only teeth with incomplete root formation, while the group ^12 yr contained only teeth with completed root formation. In order to determine whether age contained other prognostic information than that contained in stage ol root formation, the possible interaction between rocjt ibrmation and age was investigated. Because of the limited range of ages for teefh with incomplete root formation, only the effect of age on teeth with completed root formation was analyzed.
Coticussioti and subluxation

occurred in teeth with coinpleled root formation: thus, the elfect of root development could not be included in the analysis, and an independent multivariate analysis cjf ecjncussicjti and subluxatiou was, therefore, not perfbrmed.
Extrusion

From Eig. 1, it appears that no pulp neci'osis occurred at the 3-incjnth or 5-yr follow-up; these intervals were, therefore, excluded from the analysis. Because of the limited material in this luxation category, only the effeets of root formation and age were considered, lable 5 shows that when the cflects of root formation and age (either age for all teeth or age for teeth with completed root (brmation only) were eonsidered simultaneously, neither elfect was significant. In the final model, the elfeet of completed root formation was highly significant for the develc^pment of pul]:) necrosis (p = 0.0002).
Lateral luxation

'1 he frccjueney of ]julp necrosis for both luxation catcgcjrics was very low. Moreover, all ]5ul|i necrosis
212

There were several variables which, when considered individually, had a signifieant elTect cjn the development of pulp necrosis. 1 hese were considered in the multivariate analysis. Table 6 reviews the results of the analysis of variables where complete information was available.

Pulp necrosis after luxation injuries in permanent dentition

Table 4. Univariafe survival analysis. The esfimafed regression coefficienf and level of significance are given for eacfi variable and each fype of luxafion, Empfy columns represenf irrelevanf analyses (see Table 2). Luxafion cafegory: Concussion Subluxafion Variable Crown fracfure Scoring None Infracfion Uncomplicafed (in yr) Yes No Yes No Laferal luxation

Exfrusion

Intrusion

3
0 .11

P
.92 .17 .52

P
0 1.52

P
.09
.0002

P
0 .47

P
.67
.0002

P
0 1.16

P
.02
.006

P
0 -.28 .41

P
.32
.004

Afle Previous resforafion Complefed roof formafion

.05
.79 0

.07
.28 0

.20
1.02 0 2.16 0

.02
.60 0 2.78 0

.02
.70 0 1.72 0

.75

.24
.0002

.05 <io-

.07
<10-f'

No. of injured teeth In same denfal arch (quanfifafive) Year of injury <1975 1975-77 1978-81 (mm) (mm) (mm) Complefe Incomplefe None Surgical Manual Orfhodontic None CONCISE"" SCUTAN'" Cap- or acrylic splinf Sufure or no splint Orfhodonfic bands Yes No <3 h g3h None 1 2 3 Yes No Posifive Negafive Yes No

.27
0 -.55 -.74

.57 .77

.10
0 .11 .39

.65 .78

.45
0 -1.28 -1.25 -.07 -03 .79 1.96 0 1.03 0

.82 .07

.39
0 -.87 .02 .04 .00 -34 -.21 0

.0004

.08
0 -.31 .69 .09

.53 .06
.08 .53

.01

Infrusion Exfrusion Refrusion Degree of repositioning

.56 .86

.65 .95

.05 .84 .81 0 1.31 1.47 .85 0 .46 2.29 .68 0 .90 -.25 0 0 .76 0 -.36 -13 .95 -.02 0 2.64 0 -.27 0

.11

.50

.02

Reducfion procedure

.51

-.29 0 -.33 -.12

.27

.01

Type of fixafion

1.29 -.23

.45 1.15

.35
0 -.04 .29 0 0 .98

.60
0 -.25

.75

.01*

Anfibiofic therapy Pre-fixation period Degree of loosening

.65

-08 0 0 -.21

.92

-.17 0 0 .19 0 -.18 -1.06 -1.16 .24 0 -1.23 0 .27 0

.65

.37

.74

.53

.12

0 -.91 .57

.35

0 -2.10 -1.23 -.91 .60 0

.45.53* .11* .05*

.01* .57* .04*

.35* .95* .17* .48*

Tenderness fo percussion Reacfion fo pulp fesfing Pain on occlusion

-1.69 0 1.73 0

.or
.01*

-1.35 0 1.05 0

.09

1.51 0

.25

* Variables which are not registered for all feefh in invesfigafion.

In the full statistical model (Table 6, model no. 1), it api^eared that only completed root formation had a highly signifieant eifect on the development of pulp necrosis. The remaining variables did not add significant information (p = 0.06) when root fbrmation was considered. Although the number of in-

jured teeth in fhe same dental arch had a strongly signifieant effect on prognosis in the uni\ariate analysis, its elfect was not sigtiificanf in fhe muhi\ariate analysis (p = 0.32). fhis might be explained by the close association that was found between the luiniber of iiijtn ed teeth in the same dental arc h and 213

Andreasen and Pedersen

Table 5. Summary of fhe mulfivariafe survival analysis for exfrusion, giving esfimates (p) and sfandardized esfimafes (p/SE(p)) of regression parameters. Model including age for feefh wifh complefed roof formafion Covariable: Complefed roof formafion

Model including age

Model excluding age

P
.82
.10

P/SE(f>)
.72
1.59 69.61

P
1.46

P/SE(p)
1.83 1.83 68.77

P
.07 .07

P
2.16

P/SE(P)
3.46

p
.0005

.47 .11

Age
Age wifh complefed roof formafion Deviance Degrees of freedom

.12

71.97

P*

139 .12

139 .07

140

likelihood rafio fesf for reduction fo final model.

completed root formation (the relative frequency of teeth with complete root formation was 0.53, 0.67, 0.85 and 0.91 for 1, 2, 3 and 4 injured teeth in the same dental arch, respectively). When the combined effect of year of injury and root development was considered (Table 6, model no. 2), it seemed that there was a significantly improved progncjisis for teeth admitted to the study in the years 1975-1977 (p = 0.01, df=2). This factor was possibly related to a change in referral policy (see later). Inclusion of each of the incompletely recorded variables, vitality testing (missing fbr 21 teeth) and degree of loosening (missing for 2 teeth), into the final model (Table 6, no. 3) showed that when the effect of root formation was taken into acc:ount prognosis was slightly improved if the tooth reacted positively at the time of injury (p = 0.05), while degree of loosening had no signifieant effect on Jjrognosis. As inelusion of vitality testing in the final model would reduce the material by 21 teeth and as neither of the two variables had any marked effect on prognosis, the two variables were excluded from further consideration.

Intrusion

'fhis was the most serious type of injury with respect to the development of pulp necrosis and most other complications (Fig. 2 and Table 3). Although several variables had a significant or almost significant effect in the univariate analysis, only completed root formation had a significant effeet when the remaining variables were taken into account (Table 7). The combined effect of the remaining variables in model 1 was not significant when root fbrmation was included (p = 0.08). When the reduction was broken down into smaller steps, a few slightly significant effeets were encountered; that is, when the effect of year of injury and root develo]3ment were considered sinniltaneously (Table 7, model no. 2), there seemed to be a significantly improvc;d prognosis fbr teeth admitted to the study in the years 1975 1977 (p = 0.02, df=2). J he elTect of the reduction piocedtn-e was nc3 longer significant when root development was taken into aeeount. However, there was a tendency Ibr teeth which had been repositioned to have a, |)oorer |3rognosis than those which were not (]:) =

Table 6. Summary of fhe mulfivariafe survival analysis for laferal luxafion, giving esfimates (f!) and standardized esfimates (p/SE(p)) of regression parameters. Model number: 1 Covariable: Infracfion Completed roof formafion Age wifh complefed roof formafion Previous resforafion No. injured feefh in fhe same dental arch Year of injury 1975-77 1978-81 Deviance Degrees of freedom P'

P
.51 2.67 -.00 .20 .15 -J2 -.11

P/SE(P)
1.21 4.28 -.00 .64 1.00 -2.50 - .41 274.5 387 .06 .23 .00002 .99 .52 .32 .01 .68 -.94 -.04 2.80

P/SE(P)
4.82 <10-5 2.78

P/SE(P)
4.77 <10-

-2.61 - .13 277.2 391 .01

.009 .90 286.6 393

* Likelihood rafio fesf for reducfion fo final model.

214

Pulp necrosis after luxation injuries in permanent dentition

Table 7. Summary ot the muitivariate survival analysis for intrusion, giving estimates (0) and standardized estimates (p/SE(P)) ot regression parameters. Model number: 1 Covariable: Completed root formation Age with completed root formation Previous restoration Degree of lepositioning Complete Incomplete Reduction procedure Surgicai Manual Orthodontic Year of injury 1975-77 1978-81 Intrusion (mm) 1.95 -.01

372
-.64 1.42 1.11 -.40 -.50

.0002

1.83

4.89

10-'

1.74

4.62

1.72

4.72

.74 .71
-.32 -.32

.52 .16 .27 .69 .62 (-) .46 .17 .06 .33
-.64 .60 -1.68 1.61

.81 .05

2.37 0.09

.02 .93

(-)
-.40 -.59

(-)
-.74 -1.37 1.89

.99 .06

.09 .11

.97 144.7 135 .08

Deviance
Degrees of freedom P+

152.4 142 .02

154.7 142 .07

160.0 144

* Likelihood ratio test for reduction to tinal model. ( - ) Ettect could nof be estimated in the model including degree of repositioning.

O.07, cli"=2); i)articuhu'ly teeth which had been completely ropositioncd liad a worsened prognosis than non-repositioiicd teetli (p = 0.02) (Table 7, model no. 3). VN'hetlu-r the re]3ositioning iDroccdiire furtlirr traumatized the toolh or the negative prognosis merely rellected treatment strategy whereby t h e most serious injuries were treated could not be determined in the present investigalion. The effect of the type ol' lixation was no longer signilicant when the elfect o\' compli'ted lool foriiialioii
w a s i n e h i d e d in t h e slatistieal m o d e l ( p = 0 . 2 7 ) .

All luxation categories

A sUUistical model comprising llie lotal material w a s investigated in which the type of infury and stage of root formation were considered as lac-tors. However, i t appeared that the hypothesis of proportional haza r d s among luxation < ategories was not fniniled, as p u l p necrosis tended lo be diagnosed shortly after injury in tlie case ol concussion and subluxalion and relatively late alter extrusion, lateral luxation and intrusion. In conclusion, the statistical descri|3ti()n
revealed that both type of ittjttry a n d slagc of rool

formation signilicantly inlliienced pulp survival, the former via non-proportional hazartls. The lesuUing curves o f p u l p survival ai'c illustialed in Iwg. 3 A a n d H Ibr teeth with incomplete antl coiiipleied root formation, r(\s|)ec tively. Effect q/root /ortNtitioti. Tlie effect ol'root Ibrmation w a s found to be highly signilicant Ibr each luxation category. Although the estimated regression coelli-

cieius (where they could be estimated), varied for each category '$/SE($) = 2 . 1 6 / - 0.62, 2.78/0.58 and 1.72/0.36 for extrusion, lateral luxation and intrusion, respectively - the\ did not dilfer significantly irom one another (p = 0.29). tiffed of year oJ tiijiiry. For both lateral luxation and intrusion, teeth admitted to the study in the years 1975 1977 tended to ha\'e a better prognosis than teeth admitted before or after that period. A possible explanation lor this finding could be the change in policy regarding referral to the dental department at the time in question, whereby dental departments in surrounding liospitals assumed responsibility for emergency denial treatment and which temporarily resulted in a 10",, decrease in the iunnl)er ol' palients Ireated al the l'ni\ersity Hospital as well as a decrease in ihe number ol' se\ere injuries treated. Diniuiislied sexcrity was rellected by a significant decrease in the number of injured teetli in the same dental arih. Hjjeet of treatment. T he tendency in the uiiix'ariate analysis was that tee(h which were treated had a poorer prognosis with respeet to the de\'clopnient of |:)iilp necrosis llian teeth which recei\'ed no ireatmcnt; the cil'ect was only signilicant alter intrusion. There were obvious diffeiences in treatment of the 5 luxation categories. Thus, repositioning was nol performed alter concussion or siibhixatioii. Most extruded teeth (,83"o) were repositioned, always manually. Most intruded teeth (80"(,) were repositioned manually, ortliodontically or sm'gically. Tewcr laterally luxated teeth (73",,) were repositioned, usuall)' manually. The various types of 215

Andreasen and Pedersen

PULP SURVIVAL AFTER LUXATION INJURIES. Incomplete root formation.
concussion subluxation

PULP SURVIVAL AFTER LUXATION INJURIES. Coinpleted root formatiofn.

1001

-a
90-

concussion subluxation

Pal^'ia^'."
Per cent su rvivd

80-

706050-

extrusion
4030-

intnjsion

2010-

lat lux.

0-

intnjsion

Fig. 3. Ri'sullini; csfiin^acs ol'pulp siirviv.il after mullivariatc analysis: (he pidpoilioiial hazard model lor each lii.Nalion category. j \ For iricoiiipletc root loinuilioii. B. For coniplctctl root Idrmation.

fixation were employed for most of the luxation categories. However, orthodontic band/acrylic (ixation was used only on intruded teeth. Moreover, concussed or subluxated teeth were splinted only if there were other injured leeth in the dental arch. Antibiotic therapy did not appear to be related to the type of injury, other tlian having a liigher frequency after intrusive luxation. There appeared to be no clear-cut association between treatment variables and the severity of injury for each luxation category, as reflected by the number of injured teeth in the dental arch. However, after intrusion, there was a significantly greater proportion of teeth with complete root formation among the treatment group than among the nontreatment group (rejjositioning: x^ = 4-80, d f = l , p = 0.0.3; fixation: x'= 14.43, df=l, p = 0.001). In tlie concluding models, where root development was taken into account, it was not possible to demonstrate any edect from treatment. As it was not possible to disclose a definite treatment strategy, except for concussion, subluxation and in part lor intrusion, one might be justified in accepting as real the observation that treatment had no effect on the development of pulp necrosis. It must be remembered, however, that as treatment was not randomly assigned, one must l)e cautious when considering this conclusion. Discussion Pulp necro.sis was found to be a very frequent compli(ation alter luxation injuries, occurring in approximately \J5 of all eases. In this respect, it is of

interest to note that two out of 414 control teeth, teeth diagnosed as non-injured at the initial exami.nation, also developed pulp necrosis. This is in agreement with findings made by Stalhane & Hedegard (20) and could reflect either undiagnosed trauma from the time of injury or a second, unnoticed trauma. When frequency of pulp necrosis, according to the variables studied, was considered, several were found to be of possible significance. These included: presence or absence of infraction, age of patient, restorations at the time of injury, stage of root formation, number of injured teeth, degree of repositioning, reduction procedure, degree of loosening, electrometric sensibility at the time of injury, subjective symptoms (e.g. pain from occlusion and continuous pain) at the time of injury. 'I'hese findings are in agreement with previous studies. While frequency and univariate survival analyses provide a list oi probably significant variables, sucb analyses cannot reveal associations or interaction between variables. The muitivariate regression analysis of grouped survival data (21) was used to eliminate redundant variables and find those variables which alone add significant information about a tooth's prognosis after luxation. It was found that only information on type of luxation injury and stage of tool formation was necessary for such a forecast. This is in agreement with previous findings (27). The present findings imj^ly that prognosis is determined at the time of injury. As far as it was possible to evaluate, none of the treatment variables examined was found to afieet prognosis after injury with respect to the development of pulp neerosis. This

26 1

Puip necrosis after iuxation injuries in permanent dentition conclusion, however, must be considered in the light of the fact that treatment was determined by an established strategy, not by randomization. It was found that the diagnosis of pulp necrosis followed difierent chronological patterns for the different types of luxation itijuries, being diagnosed shortly after concussion and subluxation and up to 2 yr after extrusion, lateral luxation and intrusioti. Thus, the hypothesis of proportional hazards for the 5 luxation categories was not fulfilled. The diflerence in the time of diagnosis ofpulp necrosis could be explained in one of two ways: either there is a real time difference, dependent upon type of injury, or it is the diagnostic procedure itself whieh is infiuenced by the type of injury. As most evidence today indicates that pulp necrosis after injury is a rapidly occurring event (22, 23), the diagnostic procedure is perhaps the source of this difference. The luxation types where pulp necrosis is diagnosed late (i.e extrusive-, lateral- and intrusive luxation) represent traumas where extensive injury has taken place in the periapicai area. In these cases, periapicai repair must take place after the injury. During this period of repair, radiographic evaluation is uncertain because changes in the area could indicate either repair or pathological processes associated with pulp necrosis. Thus, radiographie criteria for pulp tiecrosis are difficult to e.stablisli (24). Besides potentially inadequate diagnostic criteria for pulp necrosis and possibly unrecorded factors, a weakne.ss in the present investigation could be small subgroup.s. It tnight appear that 637 luxated teeth was an adequate number for statistical analysis. However, analysis according to type of luxation injury implies that the material be broken up into 5 smaller groups. The result of this subdivision is groups where certain events occur either in almost all teeth (e.g. pulp necrosis after intrusion of teeth with completed root formation) or in none (e.g. pulp necrosis after concussion or subluxation of teeth with incomplete root formation). When only a few teeth, or almost all experience pulp necrosis, it is difficult to gain any tneanitigful itifbrmatioti on progtiostie factors. In order to relate the present findings to the etiology ofpulp tiecrosis, a working hyothesis could be that the development of pulp necrosis is related t o the initial injury to the vascular supply to the pulp, reflected by the luxation injury and the potential for repair, reflected by the stage of root formation. Using this hypothesis, the following etiology and pathogenesis for pulp necrosis could be suggested. Essential differences exist between the extent of injury to the pulp and periodontium between the 5 luxation categories. Exactly how much damage each tooth suffered can only be guessed at, as no histological examination could be performed on the teeth in the present investigation and no previous clinical or experimental study has been able to reveal it. However, concus.non and subluxation presumably represent minimal injury to the periodontium and slight injury to the pulp, as indieated by the frequent positive response elicited by electrometric pulp testing immediately after injury atid by the limited risk ofpulp necrosis after these injuries. In contrast, extrusion, lateral luxation and intrusion provide a range of pulpal, periodontal ligament and alveolar socket damage, the dilTeretice in extent being refiected by the frequency of complications seen after injury. When comparing the latter 3 types of luxation, the least datnage to the periodontium is seen after extrusion. This is because periodontal fibers are merely stretched or torn, allowing displacement of the tooth without altering socket anatomy. Intrusion can only occur when the tooth has been forced axially through the socket wall, resulting in damage to bone, periodontal ligament and perhaps the cementum layer of the root. In lateral luxation, crown displacement is typically orally, with the root apex being forced facially, ofteti with resulting fraeture of the labial botie plate. Extrusion presumably severs the pulpal vascular supply, increasing the risk ofpulp tiecrosis. Lateral luxation and intrusion presumably not only sever the pulp's blood supply, but also tesult iti a crushitig injury to the root surface and alveolar process immediately surrounding the apex, leading to further injury to the pulp and possibly limiting the potential fbr repair. The second predictor, stage of root formation, is presumably an expression of the potential for ingrowth of new vessels into the severed pulp. Itrtagine a circular apical foratnen in a tooth with incomplete root formation and an apical foramen with a 2-mm diameter, and compare that to a tooth with eompleted t-oot fbrtnation with an apical forameti of perhaps 0.5 tntn diatneter. The area available for vascular ingt-owth is increased by a factor of 16 in the open apical foramen, a factor which might explaiti the marked influence of the stage of root fortnatioti on the occurretice of pulp necrosis after itijury. Exactly the satne relationship betweeti root developtnent and pulp tieerosis has beeti foutid after autotransplantation of premolars (25). A detailed study of the relatiotiship between pulpal ditnensioti and pulp survival is in preparation. It would appear from Fig. 2 that each lvtxation category is represented by distinet survival with respect to development of pulp necrosis. But when the prognosis is analyzed accorditig to stage of root formation (Eigs. 3A and B), a similarity is observed between extrusion and lateral luxatioti. The large difference between extrusion and lateral luxation in Fig. 2 is due to the different cotnposition of the 2 groups with respect to root formatioti, i.e. 38% 217

Andreasen and Pedersen and 72'X) teeth with cotnpleted root formation in extrusion and lateral luxatioti, respectively. In the coneluditig tnodel, tooth mobility at the time of injury was fbutid not to have a significant effect on prognosis. This is in apparetit contrast to the findings made by Eklund et al. (8) that increased tooth mobility at the time of injut y itnplied a sigtiificantly worsened progtiosis. However, iti the classification system used iti the given article, "subluxation" could include concussioti, subluxation and lateral luxatioti, iti which case the above findingwould presumably rellect only the difference in prognosis between luxation categories. A covariable whicli was oti the borderlitie of sigtiificance in the univariate- and muitivariate analyses WAn year of injury. It appeared that teeth treated in the years 1975-1977 had a better prognosis thati teeth treated befbre or after that period. A (hange in referral policy to the dental departmctit duritig that titne coiikl cxplaiti this finditig. The result of tnost itivestigations has been an average frequctTcy of pulp necrosis after an average observation jjeriod. Table 8 lists the occurrence of pulp necrosis after luxation in a number of clinical studies. I h e percentages shown suggest that prognosis eati vary etiortnously. It cati be seen (Votn Fig. 3, however, that the observatioti period and composition of the material in any giveti investigation would effect the occurrence of ]3ulp necrosis. Even studies with the same average or mediati observatioti periods are tiot neeessarily comparable. For example, consider a pojaulatioti of extruded teeth with completed root fbrmation and atn average observation period of 3 tnonths. Wilh all teeth having approximately the same observation period, one would expect a 5O'X, occurrence of pul|3 tiecrosis. However, if 20% had ati observatioti period of 1 yr and 8O'X, ati observation period of 3 wk (average observation period = 3 months), the results would be api^roximately 2()'X, pul|5 tiecrosis (Fig. 3B). Only by using the actual ol)scrvation times (e.g. by the life talkie method), as in the present itivestigation, can one provide a com|)lcte pictute of the clirotiologic al dcvclo|:)tneiil of ptilp tiecrosis altei' injury. It can be further deduced that clinical investigations can yield different, even contradictory, conclusions wheti important covariablcs are ignored. Disregarding type of luxation, one tnight artive at any conclusion with respect to the eflect of root development by altering the compositioti o f a tnaterial (Figs. 3 and 4). Due to the differetit prognoses with resjject lo the dcvelopmetit of pulp necrosis and because the frequency of other complications varies between groups ('fable 3), cla.ssificatioti of luxation into 5 entities appears justified. In this regatxl the diagno.si.s "lateral luxation" must be tncntioned. Despite its spccilic patltogctiesis, tio other itivestigatioti has identified it. An importatit featute of this cliagtiosis is that, in retrospective surveys, given perhaps otily 1 radiograph atid no photographic rcgistratioti, lateral luxation cati tnimic atiy one of the other 4 luxation categories (17). When one considers that this type of luxatioti is relatively fVcquetit (20% of the present material), one might wonder in which category it was grouped in other investigations and how this might have inOuenced their results. If, a.s has beeti the case in previous investigatiotis, lateral luxation is included in any of the other injury categories, estimates of a tooth's prognosis could be distorted positively or negatively, depending on the category selected. Iti conclusion, two tnajor factors appear to explain the developtnent of pulp necrosis after luxation injuries: the extent of datnage to the pulpoperiodontal cotnplcx, tcflected iti the type of luxation itijuty, atid the (apacity of that cotn]5lex Ibr repair, reflected by (he stage of root Ibrmatioti. Moreover, treattnent was fbutid not to improve l^rogtiosis with tespect to the development of ptilp necrosis afler injttry. In light of these findings, it would appear appropriate that future luxation studies be (enfetecl arotttid randotnized clitiical investigatiotis which would examine ]3ossil)le ellccts of various treatnietit |)roccdures.

Table 8. Prevalence of pulp necrosis affer luxation injuries in fhe permanenf dentifion. No. of feefii No. of teeth wifh pulp necrosis 44 (41%) 72 (60%) 18 (24%) 98 (52%) 172(15%) 75 (38%)

Examiner Skieller (7) Weiskopf et al. (26) Anehill ef at (14) Andreasen (27) Sfalhane & Hedegard (20) Rock et al. (1)

107 121 76 189

1116

200

Acknowledgements - The authors wottld like to express their gratitude to Kell 0sterlind, M.D., research associate. Department of Oncology, The Finsen Institute, for his valuable assistance in the developtnent of computer programs used for data registration, atid to Per Kragh Andersen lit .scient.. Statistical Research Unit, Copenhagen Utiiversity, for advice and discussions of the statistical aspects of the present investigation. This investigation was supported by grants frotn Hafiiia-Haand i Haand Fondet and from the Danish Medical Research Council (grant nos. 12-3236, 12-3635).

218

Pulp necrosis after luxation injuries in permanent dentition

curred is merely registered at each of the seheduled follow-up times, ti, ... ,tT. Thus, although the actual follow-up times vary around the seheduled times tj, with larger variations for larger tj's, the observed survival times are discrete in nature. The regression analysis of grouped survival data has been applied in various diseiplines ranging from human breast cancer (21) to agricultural research (28). In the former paper, a thorough presentation of the grouped data version of the proportional hazards model of Cox (29) is gi\'cn. This will be reviewed briefly. In the Cox model, the hazard function (failure rale) for ati individual - in (he present investigation, a tooth, with eovariate veetor z = (zi,...,Z|,) is speei1 ed as: 1
X{\;L)

= A,o(t)

exp (Pz)

I'ig.

4.

Sclu'iiialic

iilustralion

ol

iho

cdci'l

of c o m i i o s i l i o n

of

n m l n i a l (in c o i u l u s i o n . s d r a w n ('icini c i i n i i a l i n x c s l i g a l i o n s . I'.acli

bar rcprcscins the level oi' pulp survival 1 yr after injury. The
up]5er set of bars re]5resents pulp .survival for teelh with ineoniplelc rdol foriiialion. and llic lower sel pulp sur\i\al for leelh vvidi complete rool formalion. If one ignored die l\ pe of luxalion injury, il would be possible lo draw (hree eoiiclusions regardins;' the elTeet of root development on prognosis after injury, dependi n g on the composition of maleriai .studied. C^onctusiun I: completed
root formation improved prognosis. T h i s eoiild he fonnd if all leelh

where P is a corresponding x'ector of unknown parameters lo be estimated, and Pz= PiZi + ...-|-PpZ,,. The unspeeificd non-negali\'e ftmetion A.()(t) denotes ihe eommon underlying hazard function and exp(Pz) the relative risk for an individual with eovariates cotnparcd hereto. The conditional probability for a gi\'en tooth to survive the pre-planned follow-tip examination at tj withoitt pulp tiecrosis, given that it has survived the previous follow-up examination at tj_iis:

with meomplcte root formation were miruded and all leelli with eompleted rool iormalion wi'ie stibhixated or eoniussed. Conclusion II: root formation had no ejject on prognosis. This eould be

found if all teeth with ineomplcle root formation were intruded and all teeth with eompleted root formation were extrtided.
Conclusion III: completed root formation worsened prognosis. This eotild
be found ii all teelli wilh iiieoniplele completed root rool formation forinalion were were inialtruded and all teelli w i t h intruded.

crally luxated or

where pj is the corresponding conditional probability Ibr z = 0. Each tooth contributes a factor pj(z) to the likelihood for eaeh of the ituervals it survives and l-pj(z) for the interval it docs not survive, i.e. given survival of the j - l ' s t interval, the contribution of the i"lh tooth from the j ' t h interval is.

Statistical appendix

where yijis the cotnplicaiioti itidicator for i'th tooth. _ ''' 1, if coni]3lication iti the j'th interval 0, otherwise

M"hc main objccUvc of ihe sludy was lo investigate t h e ellerls ol' x'ai'iou.s faetors on the progtiosis for luxaled ])ernianent leetli. A |joor prognosis was indicated ifany of the eompheatioiis studied developed. A.S the patients entetxd the study over a long period ol' lime, and as the (itne of oeeurretiee of eaeh eompliealion is registered, the data have the form of eensored survival data with eovariates. Full utilization of informatioti in sueh data requires not only the ocetu'renee, but also the time of oecurrenee, o f these complieations, as in life table analy.sis. However, beeause of the non-aeute eharaeter of the ( omplieations (in eontrast to, e.g., death in breast eancer), the exact time of oceurrenee is not registered. Whether a given eouiplieation has or has not oc-

Thus, the likelihood is equix alcnt to thai of a sample of N = 2-k; independent bitiomial distributions,
i

where kjis the number of follow-up times at which the i'th tooth is present. Applyitig the complementary log log transformation to (*), the model can be formulated as a linear regression model:
log ( log PJ(Z)) = Pz + Yj

where yj = l o g ( - I o g pj) and the model belongs to the class of generalized linear tiiodels discussed by Nelder & VVedderburn (30). Such models are ad219

Andreasen and Pedersen

ecjuately analyzed by the computer program CKNSTAT. The estimated survival function at time tjcati l)e ealeulated from the maximum likelihood estimates
0 ^ 7 = ( Y I V J T ) and P to
( r a u m a bei J u g e n d l i c h e n c i n e L o n g i l t i d i n a l tiiitcr.siK h u n g .

Dtsck Zalmarztt Z '976; 31: 938 46.

1.3. ARWIM, T , HEN.SCHEN B, SUNDWAM.-HAGI.AND I. The ptilpal

14.

J P(tj;z) =7X^
15.

It should be noted that when P = 0 the estimatioti of the survival funetion by direct estimation of the Pi's as the proportion of teeth surviving tj (out of tlie group of teeth with a potential survival of tj) is identical to the ordinary life table estimator, when only the survival times ti,...,ti are observed.

16. 17.

18.
19.

reaetion in traumatized permanent ineisors. Odont Tidskrijt 1967; 75: 130-47. ANEHII.E S, I.tNt^AHt. B, WAI.LIN 11. Prognosis of traumatised permanent ineisors in ehildren. A elinical-roentgenological after-examination. Sv Tandlak-Tid 1969; 62: 367 75. JACOISSEN I. Griteria for diagnosis of pulp neerosis in traumatized permanent ineisors. Scand J Dent Res 1980; 88: 306 12. RAVN J J . Intrusion of permanente iiuisiver. TandUigebladet 1975; 79: 643-6. ANDREASEN FM, ANIIREASENJO. Diagnosis of luxation injtiries. T h e importanee of standardized elinieal, radiograpliie and photographic teehniqties in elinieal investigations. Fndod Dent Traumatol 1985; (in press). ANtJREASEN J O . 'Traumatic injuries oJ' the teelli. 2nd ed. Gopenliagen: Munksgaard Itilernational l^iblisliers, 1981.
MOORREES G F A , I'ANNINI; f^A, IIUNT EE. Age variation of

References
1. ROOK Wl', GORDON PH, FRtENi) LA, (;RIINI)Y MC:. I h e

20.

2.

3.

4. 5.

6. 7.

relationship between trauma and pulp death in ini isor teeth. Hr Dmt J 1974; 136: 236 9. ROCK WP, GRUNDY MG. The etleet of luxation and subluxation upon the prognosi.s of Iraumalized incisor leeth.~]Dent 1981; .9.-224.30. HAAVtKKO K, RANTANEN L . A follow-up study of injuries lo permanent and primary teeth in (liildren. Proi: l-'inn Dent Soc 1976; 72: 152-62. LtiosTARiNi:N V, Ponro M, ScMEiNtN A. Dynamies of repair in the pulp. J Dent Res 1966; 45: 519 25. MAGNtjssON B, Hot.M A-K. Traumatised permanent teeth in (liildren a tbllow-up. I. Pulpal eom]jlieations and root resorption. Sv Tandtdk-Tid 1969; 62: 61-70. SKtEi.t.ER V. Om progiiosen for unge tiender med losning efter akut mekanisk tesion. TandUgeJjladet 1957; 61: 657-73. SKtEt.i.ER V. The prognosis for young injured teeth loosened after mcelianieal injtiries. .'tcta Odiintnl Scand I960- 18171-81.

21.

22.

23.

24.

ibnnalion (or len permaiieiil leelh. f DenI Res 190.3; 421490 502. SrAtjiANE I, HEDEejAffD B. Traumatized permanent teeth in children aged 7 15 years. Part 11. Swed Dent f 1975; 68157 69. PRENTICE RL, GI.OECKI.ER 1,A. Regression analysis of grouped survival data with a|j|jli( ation to breast eaneer data. Biometrics 1978; lU: 57-67. SKOCU.UND A , TRON.STAD L . I'ulpal changes in replanted and autotraiisplanted immature t<-etli of dogs, 'j lindod I 98 1 / 309 16. OitMAN A. Healing and sensitivity of pain in young rel^lanted human teeth. An experimental elinieal and histologieal sttidy. Odont Tidskr 1965; 73: 168-227. ANDUEASEN I''M. Healing events atler luxation injuries in the permanent dentition. Transient apical breakdown and its relation to eolor and eleetrometrie sensibility ehanges. Endod Dent 'liauniatol 1985; (in press). O. Progno.sis of aulolran.splanlatioii of prcmolais. A longitudinal study of 350 transplants. In ])re])aration.

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