Summary of property changes resulting from heat treatment of two gold alloys for all-metal restorations. [http://www.jelenko.com/, accessed August 15, 2012]
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Metallic materials have widespread use in dentistry for clinical treatment and restoration of teeth. Major areas of usage are: (1) restorative dentistry and prosthodontics (dental amalgam and gold alloy restorations for single teeth, metallic restorations for multiple teeth, including metal-ceramic restorations, removable partial denture frameworks, and dental implants), (2) orthodontics (wires which provide the biomechanical force for tooth movement), and (3) endodontics (rotary and hand instruments for treatment of root canals). Heat treatment of the metal can be performed by the manufacturer, dental laboratory, or dentist to alter properties intentionally and improve clinical performance. Heat treatment of the metal also occurs during the normal sequence of preparing a metal-ceramic restoration, when dental porcelain is bonded to the underlying alloy substrate. Moreover, intraoral heat treatment of some metallic restorations occurs over long periods of time. There is an enormous scientific literature on the heat treatment of metals for dentistry. A search of the biomedical literature in May 2012, using PubMed [http://www.ncbi.nlm.nih.gov/pubmed/] revealed nearly 450 articles on heat treatment of dental alloys. The purpose of this chapter is to provide a review of the heat treatment of metallic dental materials in the foregoing important areas, describing the important property changes, with a focus on the underlying metallurgical principles.
Dental amalgams are prepared in the dental office by mixing particles of a silver-tin-copper alloy for dental amalgam that may contain other trace metals with liquid mercury. The initially mixed (termed triturated) material is in a moldable condition and is placed (termed condensed) directly by the dentist into the prepared tooth cavity, where it undergoes a setting process that produces multiple phases and can require up to one day for near completion. Extensive information about the several different types of dental amalgams are provided in textbooks on dental materials [1,2]. Particles of the alloy for dental amalgam are manufactured by either lathe-cutting a cast ingot or directing the molten alloy through a special nozzle. Both the machining of the lathe-cut particles and the rapid solidification of the spherical particles create residual stress. In addition, the microstructure of the solidified silver-tin-copper alloy has substantial microsegregation. Consequently, manufacturers of the alloy powder for dental amalgam perform a proprietary heat treatment to relieve residual stresses and obtain a more homogeneous microstructure. This heat treatment is of considerable practical importance since it affects the setting time of the dental amalgam after the powder is mixed with mercury. Subsequently, the dental amalgam restorations undergo intraoral aging, which can be regarded as heat treatment, and detailed information about the microstructural phase changes for prolonged intraoral time periods has been obtained from clinically retrieved dental amalgam restorations [3].
Gold alloys are principally used for all-metal restorations (inlays, crowns and onlays) in single posterior teeth. These alloys are cast by a precision investment process, and the restorations are cemented by the dentist into the prepared tooth cavity. The original gold casting alloys contained over approximately 70 wt.% gold, but the very high price of gold has led to the development of alloys that contain approximately 50 wt.% gold. These alloys also contain silver, copper, platinum, palladium, zinc, and other trace elements, including iridium for grain refinement. Information about the dental casting process and the gold alloys is available in dental materials textbooks [1,2]. Detailed compositions and mechanical properties of specific alloys are available on the website of the major manufacturers. Another valuable reference is the current ISO Standard on metallic materials for fixed and removable dental appliances [4], which stipulates mechanical property requirements. In the normal dental laboratory procedure, gold castings for all-metal restorations are water-quenched after solidification, following loss of the red heat appearance for the sprue. This results in formation of a disordered substitutional solid solution and leaves the alloy in the soft condition, which is preferable since adjustments are more easily made on the restoration by the dental laboratory or dentist. The gold alloy casting can also be placed in the soft condition by heating at 700°C for 15 minutes and water-quenching. The quenched gold casting may be placed in the hard condition by heat treatment at 350°C for 15 minutes and air-cooling. This heat treatment results in formation of ordered AuCu or AuCu3 regions in the disordered matrix of the high-gold or lower-gold alloys, respectively. Examples of changes in clinically important mechanical properties from heat treatment are shown in Table 1 for two gold alloys, where (S) and (H) represent the soft and hard conditions.
In practice, dental laboratories do not perform heat treatments on the cast gold restorations because of the time involved. However, it appears to be fortunate that the gold alloys that contain sufficient copper to undergo ordering will undergo age hardening in the mouth. Figure 1 compares the intraoral aging behavior of a traditional high-gold dental alloy (Type lV) and a special gold alloy containing gallium (AuCu-3wt%Ga) [5].
Alloy | Vickers Hardness | 0.2% Offset Yield Strength | Percentage Elongation | |||
Firmilay (74.5% Au) | 121 (S) | 182 (H) | 207 MPa (S) | 276 MPa (H) | 39% (S) | 19% (H) |
Midas (46% Au) | 135 (S) | 230 (H) | 345 MPa (S) | 579 MPa (H) | 30% (S) | 13% (H) |
Summary of property changes resulting from heat treatment of two gold alloys for all-metal restorations. [http://www.jelenko.com/, accessed August 15, 2012]
Comparison of the two-week aging behavior at 37°C for a high-gold dental alloy and a dental gold alloy containing gallium that was designed to undergo intraoral aging. From [
Metal-ceramic restorations are in widespread clinical use for restorative and prosthetic dentistry, and are employed for single-tooth restorations and for restorations involving multiple adjacent teeth (fixed prostheses or crown-and-bridgework). An alloy is cast using the precision investment procedure in dental laboratories to fit accurately to the prepared tooth or teeth, and to form a substrate (termed the coping) for the porcelain. After an initial oxidation step that forms a native oxide on the metal surface, one or two layers of opaque porcelain are bonded to the metal, followed by the application of a layer of body porcelain and a surface glaze [1,2]. In order to have a strong bond between the porcelain and metal, which is essential for clinical longevity of the metal-ceramic restoration, the coefficients of thermal contraction for the metal and porcelain must be closely matched, and a difference not exceeding 0.5 ppm/°C is generally desired. Mechanical property requirements for the alloys are stipulated in ANSI/ADA Specification No. 38 (ISO 9693) [6], and the minimum value of 250 MPa for the 0.2% offset yield strength is important, since the thin coping must withstand intraoral forces without undergoing permanent deformation. The metal-ceramic bond strength (termed the bond compatibility index) is measured with a three-point bending test that uses thin cast alloy strip specimens having a centrally located area of sintered porcelain, and a minimum bond strength (shear stress) of 25 MPa is stipulated.
Both noble and base metal alloys are used for bonding to dental porcelain. The current American Dental Association classification has four alloy groups for fixed prosthodontics [7]: (1) high-noble (gold-platinum-palladium, gold-palladium-silver and gold-palladium); (2) noble (palladium-silver, palladium-copper-gallium, and palladium-gallium); (3) predominantly base metal (nickel-chromium and cobalt-chromium); (4) titanium and titanium alloys. Information about these alloys for metal-ceramic bonding is summarized in a textbook on fixed prosthodontics [8]. The principal mechanisms for metal-ceramic bonding are (a) mechanical interlocking from the initially viscous porcelain at the elevated sintering temperatures flowing into microirregularities on the air-abraded cast metal surface and (b) chemical bonding associated with an interfacial oxide layer between the metal and ceramic. These two mechanisms are evident from photomicrographs, found in numerous references [8], of the fracture surfaces for metal-ceramic specimens prepared from a wide variety of dental alloys. This native oxide forms on the cast alloy during the initial oxidation firing step in the dental porcelain furnace. Noble alloys for bonding to dental porcelain contain small amounts of secondary elements, such as tin, indium and iron, which form the native oxide and also increase the alloy strength. However, Mackert et al [9] found that during initial oxidation heat treatment, metallic Pd-Ag nodules formed on the surface of a palladium-silver alloy for metal-ceramic restorations and only internal oxidation occurred for the tin and indium present in the alloy composition. They concluded that porcelain bonding arose predominantly from mechanical interlocking with the nodules. Internal oxidation has also been reported for high-gold [10] and high-palladium [11] alloys for bonding to porcelain, but both alloy types also formed surface oxides [10,12].
The initial oxidation step and subsequent sintering (also termed baking or firing) of the dental porcelain layers causes the alloy to experience substantial heat-treatment effects. Under normal dental laboratory conditions, the porcelain firing sequence is performed rapidly. For example, in one study heating of high-palladium alloys in the dental porcelain furnace was performed at approximately 30°C/min over a temperature range from 650°C to above 900°C, and the total heating time for the several firing cycles at these elevated temperatures was about 45 minutes [11]. Studies [13-15] have shown that the as-cast microstructures of noble metal alloys for bonding to porcelain are highly inhomogeneous in the initial as-cast condition, presumably from substantial elemental microsegregation that occurs during the rapid solidification involved with casting into much cooler investment [1,2]. After simulation of the dental porcelain firing sequence, the noble metal alloy microstructures become substantially homogeneous, and there are accompanying changes in the mechanical properties, as shown in Table 2.
Peaks in Vickers hardness for heat treatments at temperatures that span the porcelain-firing temperature range indicate that influential precipitation processes can occur in some noble alloys for fixed prosthodontics [13,16]. For the gold-palladium-silver alloy in Table 1, heating an as-cast specimen to 980°C caused a pronounced decrease in Vickers hardness, and subsequent heat treatments at temperatures from 200° to 980°C revealed a pronounced peak in Vickers hardness at approximately 760°C. The absence of substantial changes in Vickers hardness for similar heat treatments of the gold-palladium alloy in Table 2 arises from differences in the precipitates that form in the two complex alloy compositions. Figure 2 presents the age hardening behavior of a palladium-silver alloy, where specimens were subjected to isothermal annealing for 30 minute time periods at temperatures from 400°C to 900°C that span the range for the porcelain firing cycles [16]. Bulk values of Vickers hardness were obtained with 1 kg loads, and 25 g loads were used to obtain hardness values for specific microstructural regions. In contrast, research suggests that microstructures of popular nickel-chromium base metal alloys used with dental porcelain are not changed substantially during dental laboratory processing [17].
Alloy Type | Vickers Hardness | 0.2% Offset Yield Strength | Percentage Elongation | |||
Au-Pd-Ag (Neydium) | 199 (C) | 218 (P) | 420 MPa (C) | 490 MPa (F) | 6% (C) | 8% (F) |
Au-Pd (Olympia) | 213 (C) | 225 (P) | 500 MPa (C) | 540 MPa (F) | 13% (C) | 20% (F) |
Mechanical properties for two noble metal alloy types used with dental porcelain, comparing the as-cast condition (C) and simulated porcelain firing heat treatment (F) [13].
Annealing behavior of a palladium-silver alloy for fixed prosthodontics, showing changes in Vickers hardness for a heat treatment temperature range that spans the porcelain firing cycles. Reproduced from [
Base metal casting alloys (nickel-chromium, cobalt-chromium and cobalt-chromium-nickel) are popular for fabricating the metallic frameworks for removable partial dentures because of their lower cost [1,2]. Once an active area of dental metallurgy research, studies have found that these alloys have dendritic microstructures in the as-cast condition, because of the absence of suitable grain-refining elements, and that heat treatment is ineffective for producing improved mechanical properties [18]. A more recent publication shows the dendritic microstructures of some current alloys and their mechanical properties [19].
Removable partial denture frameworks have clasps that engage the teeth. These clasps can be cast as part of the entire framework, or alternatively wire clasps can be joined to the cast framework in the dental laboratory [1,2]. Both noble metal and base metal wires for clasps are available [20]. Because of their superior strength compared to the cast base metal alloys, wire clasps with smaller cross-section dimensions can be used with the frameworks, but caution is required during joining in the dental laboratory to avoid overheating that will cause loss of the wrought microstructure. Wire clasps are used in the as-received condition; heat treatment is not recommended before joining to the framework.
Dental implants in current widespread clinical use are manufactured from CP (commercially pure) titanium or Ti-6Al-4V, and some implants have a thin bioceramic surface coating (typically hydroxyapatite, the principal inorganic constituent of bone and tooth structure). Proprietary heat treatments [21] are performed on Ti-6Al-4V by manufacturers to obtain optimum microstructures for the implants; minimal information is currently available about these microstructures in the dental scientific literature.
Recently, there has been considerable research interest in the development of new titanium implant alloys for orthopedic applications that have improved biocompatibility compared to the Ti-6Al-4V alloy in widespread current use. There is particular interest in the beta-titanium alloys which have lower elastic modulus than Ti-6Al-4V to minimize stress shielding and subsequent loss of the surrounding bone which has a much lower elastic modulus. Stress shielding does not seem to be of concern for dental implants, presumably because of the threaded designs. Biocompatible titanium-niobium-zirconium beta alloys have been investigated, and oxide nanotubes can be grown on the alloy surface by an anodization technique, and subsequent heat treatment can be employed to modify the structure of the nanotubes [22]. In another exciting research area, titanium oxide nanowires have been recently grown on both CP titanium and Ti-6Al-4V using special elevated-temperature oxidation heat treatments in an argon atmosphere with low oxygen concentrations [23]. Both of these special types of surface oxide layers may prove to be useful for dental and orthopedic implants, but future testing in animals will be needed to examine their efficacy.
Orthodontic wires engaged in brackets that are bonded to teeth, after being deformed elastically during initial placement, provide the biomechanical force for tooth movement during unloading. There are four wire types in current clinical practice: stainless steel, cobalt-chromium, beta-titanium and nickel-titanium [24]. The clinically important mechanical properties are (a) elastic modulus, which is proportional to the biomechanical force when wires of similar dimensions are compared; (b) springback, which is generally expressed as the quotient of yield strength and elastic modulus (YS/E), and represents the approximate strain at the end of the clinically important elastic range; and (c) modulus of resilience, expressed as YS2/2E and representing the spring energy available for tooth movement. (The permanent deformation portion of orthodontic wire activation is ineffective for tooth movement.) Round orthodontic wires are manufactured by a proprietary drawing sequence that involves several stages with intermediate annealing heat treatments. Rectangular orthodontic wires are manufactured by a rolling process utilizing a Turk’s head apparatus. The wire drawing process with the heat treatments greatly affects mechanical properties.
A recent study that investigated stainless steel wires used in orthodontic practice found that most products were AISI Type 304 and that AISI Type 316L (low carbon) and nickel-free ASTM Type F2229 were also available [25]. While standard physical metallurgy textbooks consider the elastic modulus to be a structure-insensitive property, research has shown that the permanent deformation and heat treatments involved with the wire drawing process can substantially affect the elastic modulus of stainless steel orthodontic wires [26,27]. X-ray diffraction has revealed that conventional orthodontic wires manufactured from AISI Types 302 and 304, while predominantly austenitic structure, can contain the α′ martensitic phase, depending upon the carbon content and temperatures involved with the processing [28]. The presence of this martensitic phase accounts for the reduction in elastic modulus for some conventional stainless steel orthodontic wires. In addition, when fabricating complex stainless steel appliances, it is recommended that orthodontists perform a stress-relief heat treatment to prevent fracture during manipulation; a heating time up to 15 minutes and a temperature range of 300° to 500°C appears to be acceptable [29-31]. Heating austenitic stainless steel to temperatures between 400° and 900°C can result in chromium carbide precipitation at grain boundaries and cause the alloy to become susceptible to intergranular corrosion, and heating of austenitic stainless steel wires above 650°C should not be done because loss of the wrought microstructure causes degradation of mechanical properties.
The cobalt-chromium orthodontic wire (Elgiloy) marketed by Rocky Mountain Orthodontics (Denver, CO, USA) contains 40% Co, 20% Cr, 15.81% Fe, 15% Ni, 7% Mo, 2% Mn, 0.15% C carbon and 0.04% Be beryllium (https://www.rmortho.com/, accessed August 15, 2012). Four different tempers (spring quality) are available, and the soft Blue temper is favored by many orthodontists because the wire is easily manipulated in the as-received condition, and then heat treated to increase the yield strength and modulus of resilience. Heat treatment (not recommended for the most resilient temper) is conveniently performed with the electrical resistance welding apparatus commonly used in orthodontic practice, and the manufacturer provides a special paste that indicates when the heat treatment is complete. Alternatively, furnace heat treatment performed at 480°C for 5 minutes has been found to give satisfactory results [32]. An extensive study employing furnace heat treatment (480°C for 10 minutes) for three tempers and numerous sizes of the Elgiloy wires observed increases of 10% – 20% in elastic modulus and 10% – 20% in 0.1% offset yield strength, which resulted in substantial improvement of the modulus of resilience [27]. These changes in mechanical properties arise from complex precipitation processes during heat treatment that are not understood. Many other companies now market cobalt-chromium orthodontic wires, but studies of their mechanical properties and the results of heat treatment have not been reported.
Beta-titanium orthodontic wires have the advantages of: (a) known biocompatibility from the absence of nickel in the alloy composition; (b) lower elastic modulus than stainless steel and cobalt-chromium wires, which provides more desirable lower orthodontic force for tooth movement; (c) higher springback than stainless steel and cobalt-chromium wires, which is desirable for the archwire to have greater elastic range; and (d) high formability and weldability, which are needed for fabrication of certain appliances [24]. A recent study [25] of commercially available titanium-based orthodontic wires revealed that most products are Beta III alloys [21] containing approximately 11.5 Mo, 6 Zr, and 4.5 Sn, similar to the original beta-titanium wire introduced to orthodontics [33,34]. Beta C [21] and Ti-45Nb beta-titanium and Ti-6Al-4V (alpha-beta) wire products are also available [25]. Heat treatment is not performed by the orthodontist on these wires, but care with the wire drawing and intermediate heat treatments by the manufacturer are essential for obtaining the desired mechanical properties. These processes must be conducted under well-controlled conditions because of the highly reactive nature of titanium.
Following the pioneering work of Andreasen and his colleagues [35,36], near-equiatomic nickel-titanium (NiTi) wire was introduced to orthodontics by the Unitek Corporation (now 3M Unitek) [37]. This wire had the advantages of a much lower elastic modulus than the stainless steel and cobalt-chromium wires available at the time and a very large elastic range. The clinical disadvantage is that substantial permanent deformation of this wire is not possible to obtain certain orthodontic appliances that can be fabricated with the three preceding, highly formable, alloys. The original nickel-titanium wire had a work-hardened martensitic structure and did not exhibit the superelastic behavior (termed pseudoelasticity in engineering materials science) or the true shape memory characteristics displayed by subsequently introduced NiTi wires [1,38-41]. These nickel-titanium wires have been a very active area of research.
The mechanical properties of the nickel-titanium orthodontic wires are determined by the proportions and character of three microstructural phases: (a) austenite, which occurs under conditions of high temperature and low stress; (b) martensite, which occurs under conditions of low temperature and high stress; and (c) R-phase, which forms as an intermediate phase during the transformation between martensite and austenite. Very careful control of the wire processing and associated heat treatments, along with precise compositional control, by the manufacturer are needed to produce nickel-titanium wires with the desired superelastic, nonsuperelastic, or shape memory character [42,43].
Heat treatments have been exploited by manufacturers to control the orthodontic force ranges produced by nickel-titanium archwires [39]. Heat treatment temperatures have ranged from 400° to 600°C with times from 5 minutes to 2 hours [39,40]. Effects of heat treatment on cantilever bending plots for two sizes of a round superelastic nickel-titanium wire are presented in Figure 3 [40].
Effects of heat treatments on cantilever bending plots for 6 mm test spans of a superelastic nickel-titanium orthodontic wire. Reproduced from [
Loss of superelastic behavior occurs for the 2 hour heat treatment at 600°C, evidenced by the large decrease in springback (difference between the original deflection of 80 degrees and the final angular position on unloading). Heat treatment at 500°C for 10 minutes had minimal effect, while heat treatment for 2 hours caused a decrease in the average superelastic bending moment during the unloading region of clinical importance. Bending properties for nonsuperelastic wires were only slightly affected by these heat treatments. In addition to the use of furnace heat treatment, electrical resistance heat treatment [44] has also been exploited by one manufacturer to produce archwires where the level of biomechanical force varies with position along the wire [24].
Microstructural phases at varying temperatures in nickel-titanium orthodontic wires and their transformations are conveniently studied by differential scanning calorimetry (DSC) [45]. Temperature-modulated DSC provides greater insight into the transformations than conventional DSC [46]. Figures 4 and 5 present temperature-modulated DSC heating curves for shape memory and superelastic nickel-titanium orthodontic wires, respectively. The transformations involving austenite (A), martensite (M) and R-phase (R) are labeled. The austenite-finish (Af) temperature for completion of the transformation from martensite to austenite on heating is determined by the intersection with the adjacent baseline of a tangent line to the peak for the final transformation to austenite [47].
Heating temperature-modulated DSC plot for a shape memory nickel-titanium orthodontic wire. Reproduced from [
Heating temperature-modulated DSC plot for a superelastic nickel-titanium orthodontic wire. Reproduced from [
The Af temperature is below body temperature (37°C) for nickel-titanium wires that exhibit shape memory in the oral environment. The superelastic nickel-titanium wires have Af temperatures that are greater than mouth temperature and have more widely separated peaks for the successive transformations from M →R and R → A. The nonsuperelastic wires have much weaker transformations (lower values of enthalpy [ΔH]) and Af temperatures that are also greater than mouth temperature [45]. Examination of x-ray diffraction patterns for nickel-titanium orthodontic wires revealed the effects of heat treatment on the Ms temperature for the start of the cooling transformation to martensite as well as the occurrence of stress relief and perhaps some recrystallization [24,48].
Transformation of a low temperature martensite phase (M′) to the higher temperature form of martensite (M), shown in Figures 5 and 6, is readily detected as a large exothermic peak on the nonreversing heat flow curves from temperature-modulated DSC. Transmission electron microscopy has revealed that this transformation arise from low-temperature twinning within the martensite structure [49].
Traditionally, endodontic treatment was performed with stainless steel hand files and reamers to remove the injured or diseased dental pulp from the root canals of teeth. While conventional elevated-temperature heat treatment is not recommended for these instruments, they are subjected to sterilization procedures before being using again with a different patient. One study found that dry heat sterilization (180°C for 2 hours) and autoclave sterilization (220 kPa pressure and 136°C for 10 minutes) slightly decreased the flexibility and resistance to torsional fracture of the instruments but they still satisfied the requirements for minimum angular deflection in the ISO standard [50]. Further research is needed to gain insight into the metallurgical origins of the property changes.
Following the pioneering work of Walia et al that introduced the nickel-titanium hand file to the endodontics profession [51], engine-driven rotary instruments were introduced that enable rapid instrumentation of root canals. These instruments are in widespread clinical use, and research on the nickel-titanium files has been a highly intensive area of research.
The major mechanical property of the equiatomic nickel-titanium alloy that led to replacement of the traditional austenitic stainless steel files was the much lower elastic modulus of NiTi, which enabled curved root canals to be negotiated with facility. An excellent review article [52] describes the manufacturing process for the nickel-titanium files, which are generally machined from starting wire blanks. The conventional nickel-titanium rotary instruments have been fabricated from superelastic nickel-titanium blanks.
Defects caused by the machining process and metallurgical flaws in the starting blanks, along with inadvertent overloading by the clinician, can result in fracture of the file within the root canal, which causes considerable patient anguish since the broken fragments often cannot be easily retrieved [53,54].
A recent study investigated the effect of heat treatment on conventional nickel-titanium rotary instruments, using temperature-modulated DSC and Micro-X-ray diffraction [55]. Results are shown in Figure 6 (a) – (d) for heat treatment at temperatures from 400° to 800°C in a flowing nitrogen atmosphere.
Temperature-modulated DSC reversing (R), nonreversing (NR) and total (T) heat flow curves for specimens from conventional rotary endodontic instruments after heat treatment in flowing nitrogen for 15 minutes at (a) 400°, (b) 500°, (c) 600° and (d) 850°C. From [
Heat treatment between 400° and 600°C increased the Af temperature for as-received conventional NiTi rotary instruments to approximately 45° – 50°C, and the transformations between martensite and austenite were changed to a more reversing character than nonreversing character [55]. Heat treatment in a nitrogen atmosphere might lead to a harder surface from the formation of nitrides [56], which is beneficial for cutting efficiency of the rotary instrument. This research suggested that heat treatment at temperatures near 500°C in a nitrogen atmosphere might yield the optimum microstructure and mechanical properties, with improved resistance to deformation and fracture for conventional NiTi rotary instruments. Heat treatment at temperatures exceeding 600°C should not be performed, since the superelastic behavior is lost along with potential degradation of the wrought microstructure [24]. Another study has reported that heat treatment at 430° and 440°C greatly improved the fatigue resistance of one conventional rotary instrument product [57].
New nickel-titanium rotary instruments have been marketed, for which the wire blanks were improved by special proprietary processing techniques, including heat treatment. The first notable example was M-Wire, named for its stable martensitic structure [58]. Previous conventional rotary instruments were fabricated from superelastic wire blanks with evident transformable austenite detected by conventional DSC [59]. However, when the conventional instruments were cooled far below room temperature to attain the fully martensite condition, the enthalpy changes for transformations from martensite to austenite were far below those for superelastic orthodontic wires [44,45], indicating that these instruments contain a substantial proportion of stable martensite in their microstructures.
Two different batches of M-Wire (termed Type 1 and Type 2), with unknown differences in proprietary processing, were obtained for characterization by temperature-modulated DSC and Micro-X-ray diffraction [58]. Figure 7 shows the differences in the temperature-modulated DSC plots for (a) conventional superelastic wire and (b) Type 1 M-Wire.
Comparison of temperature-modulated DSC total heat flow for (a) conventional superelastic wire and (b) Type 1 M-Wire. Lower curves are the plots for the heating cycles. Reproduced from [
The general appearances of the temperature-modulated DSC plots in Figure 7 (a) and (b) are similar. However, the approximate Af temperatures for the conventional superelastic wire and Type 1 M-Wire were approximately 15°C and 50°C, respectively. The approximate Af temperature for the Type 2 M-Wire was 45°C. The proportions of the different NiTi phases were quite different for Type 1 and Type 2 M-Wire, as shown in Figure 8.
The Micro-X-ray diffraction pattern indicated that Type 1 M-Wire had an austenitic structure, and the Micro-X-ray diffraction pattern from the conventional superelastic wire was similar. In contrast, the Micro-X-ray diffraction pattern from Type 2 M-Wire contained additional peaks for martensite and R-phase, along with peaks for austenite. However, when M-Wire was examined by transmission electron microscopy, a heavily deformed martensitic structure was found [58]. The explanation is that the DSC peaks only reveal NiTi phases that are capable of undergoing transformation and that (stable) heavily deformed martensitic NiTi only produces weak x-ray diffraction peaks. Rotary instruments fabricated from M-Wire have been found to have similar Af values, microstructures and Vickers hardness, so the machining process and other proprietary fabrication steps do not appear to markedly alter the inherent structure and properties of the starting blanks [60].
Micro-X-ray diffraction patterns for (a) Type 1 M-Wire and (b) Type 2 M-Wire. Peaks for austenite (A), martensite (M) and R-phase (R) are labeled. Reproduced from [
Recently, new nickel-titanium rotary instruments have been introduced, in which the wire blank is heated to an appropriate temperature for transformation to the R-phase and twisted, along with repeated heat treatment and other subsequent thermal processing; instruments have been characterized by conventional DSC and cantilever bending tests [61]. Another recent study has characterized several new nickel-titanium rotary instruments by DSC and conventional x-ray diffraction, along with optical and scanning electron microscopic examination of their microstructures, including use of energy-dispersive x-ray spectroscopic analyses (SEM/EDS), to investigate the martensitic microstructures and composition of precipitates [62]. Because of the potentially great commercial importance, development of new rotary instruments with improved clinical performance is expected to remain an area of intensive research, along with study of the role of heat treatment [63].
It is essential to appreciate the complexity of the physical metallurgy of the nickel-titanium alloys and the effects of the severe thermomechanical processing of the starting wire blanks, along with heat treatments and machining of the wire blanks, on the metallurgical structure. Transmission electron microscopy and electron diffraction remain the best techniques to gain insight into the instrument microstructures and elucidate the relationships with mechanical properties and clinical performance.
Tooth avulsion is a very serious traumatic dental injury (TDI) as tooth loss may remarkably compromise the patient in both functional and psychological aspects [1, 2].
Among all dental traumas, avulsion of the permanent tooth accounts for up to 16% of all dental injuries and constitutes the most serious one. It is considered as one of the few emergency situations in dentistry [3]. By definition, tooth avulsion refers to the total displacement of the tooth out of its alveolar socket (Figure 1) [4]. Presence of the tooth outside the socket leads to deterioration of the pulp and periodontal ligaments (PDLs) due to the lack of blood and nerve supply to their cells in addition to the unfavorable external environment such as dryness and possible contamination [5]. This may end up with periodontal attachment damage, pulp necrosis, and eventually tooth loss [6]. The maxillary central incisors are the most frequently involved teeth; boys and the age group of 7–11 years old are more susceptible to this type of trauma [7].
Tooth avulsion refers to the total displacement of the tooth out of its alveolar socket.
The prevalence and incidence of reported traumatic dental injuries (TDIs) have significantly been affected during COVID-19 pandemic. In a retrospective analysis conducted at King’s College Hospital Dental Institute in London, UK, there was around 46% reduction in presented cases with TDIs during the COVID-19 compared to the year before for the same period of time [8]. With respect to avulsion injuries, the study revealed a remarkable decline in cases by around 93%. It also showed an increase in the mean delay in presentation following TDIs from 2.4 days the year before to 5.3 days during COVID-19 [8]. The reasons behind these changes were mostly related to the lockdown and forcible closure of dental practices during the pandemic. Although the urgent dental cares services in hospitals were mostly available worldwide, patients were hesitant to reach out to such centers due to the perceived fear of acquiring viral infections. Other studies also showed the same steep reduction in reported TDIs and traumatic injuries generally during COVID-19 [8, 9, 10].
According to previous studies, demographic data of reported cases has not differed between COVID-19 and years before except having less admitted cases in group age older than 70-year-old [8].
The etiology of tooth avulsion varies according to the type of dentition. Avulsion in primary dentition is typically a result of hard objects hitting the teeth, whereas avulsion in permanent dentition is generally a result of falls, fights, sport injuries, automobile or bicycle accidents, and domestic abuse. In permanent and primary dentition, avulsion generally occurs in the maxilla, and the most affected teeth are the maxillary central incisors (Figure 2). Increased overjet and incompetent lips were identified as potential etiological factors in such avulsion cases [11, 12, 13]. In rare cases, iatrogenic teeth avulsion during other procedures might happen and were reported in the literature [14, 15, 16, 17].
Maxillary central incisors are the most frequently involved teeth in avulsions.
Several factors should be considered [18], when treating a patient with an avulsed permenant tooth (Figure 3):
Patient’s age
Medical status
Root development
Development of the dentition and of the face
Extra-oral time
Storage medium
Damage associated with the avulsed tooth
Factors should be considered in the treatment of tooth avulsion.
Multidisciplinary approach in avulsion injuries is essential and considered a cornerstone during the management process. Though the management of avulsions is highly dependent on the early actions taken following the trauma and the time spent till reaching out healthcare services, this is furthermore affected during COVID-19 pandemic due to international lockdowns and restricted accessibility to hospitals. Such times clearly signify the importance of public awareness of first-aid measures in TDIs, especially avulsion.
International guidelines have been proposed to address TDIs and avulsions injuries. According to the International Association of Dental Traumatology (IADT) guidelines [19, 20, 21] and the European Society of Endodontology position statement [22], certain systematic approach has to be adopted to treat teeth avulsions. Obviously, tooth avulsion leads to necrosis of disrupted pulp which requires endodontic treatment.
We will be talking about the management for teeth avulsion and treatment choices during COVID-19. Best approach to treat an avulsed permanent tooth is immediate replantation. Whether the case is admitted to emergency clinic or people at trauma site are instructed on phone, the following steps are to be considered:
Take self-precautions while treating others at the emergency cite including wearing masks and personal protective equipment (PPE) if possible, to avoid viral infections. However, gold standard treatment always should be provided, even if dental aerosol-generating procedures (AGPs) are likely to be involved [23].
Calm the patient down.
Always aim for immediate replantation. If replantation cannot be done at the trauma site by surrounding peoples/parents/others, the tooth has to be stored as soon as possible in a storage media; milk, Hanks’ Balanced Salt Solution (HBSS), saliva, saline, or water. This is to avoid root surface dehydration. Then tooth can be replanted immediately at the emergency clinic.
Before replantation, tooth could be rinsed under running milk or saline to clean any dirt. It must be hold by the crown without touching root. Replanting primary teeth is contraindicated.
After tooth replantation, patient is asked to bite on gauze.
History: Review patient history in case of any other injury (potentially more serious) is involved, simultaneously. If any vomiting, headache, unconsciousness, or drowsiness are reported, this should be further investigated at the hospital, and also, if there is a previous injury to the teeth or the alveolar bone or if the occlusion has further changed.
How, when, and where the trauma/accident happened are all questions that should be answered. This will further help in evaluating the trauma for legal and insurance purposes. Any suspected abuse should be reported to local authority.
Anesthesia: administering local anesthesia is always recommended, preferably without vasoconstrictor [20].
Recent guidelines have detailed the plan on replanting tooth according to two main factors:
Extra-oral dry time: being less or more than 60 min.
Root maturation: closed or open apex.
For extra-oral dry time, it is used to assess periodontal ligament (PDL) cells’ viability. The soonest the tooth is replanted, within 15 min, the most likely PDL cells are viable. When the extra-oral dry time exceeds 60 min, it is more likely that PDL cells are nonviable. In all situations, it is recommended to replant the tooth acknowledging that prognosis is best when replantation is within 15 min and poorest when it is after 60 min [20]. Ankylosis-related (replacement) root resorption is an expected outcome in cases of late tooth replantation [18, 20, 24].
These factors are the patient’s general health, the maturity of the root, the time the tooth is out of its socket, storage medium [11, 25, 26, 27], extra-alveolar permanence period, means of preservation, contamination, manipulation, and conditions of the avulsed tooth [28], and also relevant factors such as type of splint used and time of permanence (Figures 4 and 5).
.
Factors might influence the success of tooth replantation.
Potential complications following tooth replantation.
Successful healing after replantation may occur only if the damage to the PDL cells was minimal. Immediate replantation of the avulsed tooth into the socket at the site of the trauma has been suggested to prevent further damage to the PDL cells left on the root surface from desiccation. As this is not always attainable since the lay person at the trauma site may lack the skill and the willingness to try this procedure. In such situations, it is recommended to put the avulsed tooth temporarily in a storage medium capable of preserving PDL cells viability. Thus, the extra-alveolar dry time and the type of storage medium are the most critical factors. Prolonging the duration of dry storage causes necrosis of the PDL cells after 30–60 min and decreases greatly the chances of healing after replantation [29].
No or minimal microbial contamination.
Readily available or accessible.
Physiologically compatible pH and osmolality to maintaining PDL cell viability.
The pH of the environment should be around 6.6–7.8 to maintain cell growth.
Optimal osmolality is 230–400 mOsmol/kg.21 as it affects water absorption of the cells.
In their quest for an ideal storage media, a wide variety of materials have been tested by a lot of researchers for their role as potential storage media. The recent guidelines of IADT recommend in descending order of preference, milk, HBSS (Hanks’ Balanced Salt Solution), saliva, or saline as suitable and convenient storage mediums. Water is considered a poor medium but is better than dry storage. Other materials, some with promising results, include ViaSpan, propolis, and egg white [20, 30].
Many authorities recognized milk as the most recommended storage medium for avulsed teeth. The ease of obtaining it at accident sites makes it a practical choice. The physiological properties of milk are significantly better than other solutions, and pH (6.5–7.2) and osmolality (270 mOsm/kg) are compatible with PDL cells. Milk contains a combination of nutritional substances such as amino acids, carbohydrates, and vitamins capable of maintaining PDL cell viability. In addition, the presence of epithelial growth factor stimulates the proliferation and regeneration of epithelial cell rests of Malassez and activates the alveolar bone resorption. Hence, the bone tissue may be isolated from the tooth and decreases the chances of ankylosis [30, 31]. However, it should be noted that few reports argued that replanted teeth stored in milk were subject to ankylosis [32, 33, 34].
The HBSS is a sterile, isotonic, and physiologically balanced standard saline solution which is used in biomedical research to support the growth of many cell types. It is a nontoxic solution, biocompatible with PDL cells; its pH (7.2) and osmolality (320 mOsm/kg) are balanced and considered almost ideal. It is composed of glucose, sodium, calcium, potassium, and magnesium ions.
HBSS is highly recommended for its ability to provide long-term preservation of PDL cells viability and proliferation capacity. Its ingredients may further help to reconstitute the depleted cellular components of the PDL. HBSS is commercially available as “Save-A-Tooth.” However, it is not found at most of the accident sites; this makes it an impractical storage medium [20, 29, 31, 32, 34].
The only advantage of saliva as a storage media is its ease of availability immediately on almost all accident sites. However, it presents a possible source of bacterial contamination for PDL cells. Its osmolality (60–70 mOsm/kg) is considerably lower than the physiological osmolality; thus, cells stored in saliva show swelling and membrane damage. Saliva is better than tap water or dry storage, but it can be used only for very short storage time [29, 30, 31].
Normal saline, a 0.90% NaCl solution, has a physiological osmolality of 280 mOsm/kg which is compatible with the PDL cells. However, it is deficient in the essential nutrients, such as glucose, magnesium, and calcium which are needed to the normal metabolic functions of the cells of the PDL. Moreover, the hypotonic properties of saline induce rapid cellular lysis. Therefore, saline is not a good storage media unless for short periods only [29, 31].
Viaspan is a cell culture media widely used for storing and transporting organs to be transplanted. It has 320 mOsm/kg osmolality and 7.4 pH which favors cell growth and viability of the PDL cells. It is nearly an ideal material for storage of avulsed teeth for long periods. However, its high cost, short vitality expiration, and the limited access to it especially at the accident sites make it difficult to find and use this storage medium [31, 35].
Egg white is considered a good storage media because of its high protein content, vitamins, and water. It is easily accessible and lacks microbial contamination with a pH of 8.6–9.3 and osmolality of 258 mOsmol/kg. Thus, it favors PDL cells viability and healing and presents a suitable choice for extended storage time [29, 31].
Tap water has an approximate osmolality of 30 mOsm/kg and a pH of 7.4–7.79. It is not considered a suitable storage medium for avulsed teeth. It has bacterial contamination; its hypotonicity and nonphysiologically pH and osmolality favor the PDL cell lysis. Cells stored in water did not maintain their viability. However, it is better than dry storage and should be used only when there are no other alternatives (Table 1 and Figure 6) [29, 31].
Storage media | Osmolality (mOsmo/kg) | pH | Efficacy | Accessibility |
---|---|---|---|---|
Milk | 270 | 6.5–7.2 | ✓ | ✓ |
HBSS | 270–290 | 7.2–7.3 | ✓ | |
Saliva | 60–70 | 6.3 | ✓ | |
Saline | 280 | 7 | ✓ | |
Viaspan | 320 | 7.4 | ✓ | |
Egg white | 258 | 8.6–9.3 | ✓ | ✓ |
Tap water | 30 | 7.4 7.79 | ✓ |
Characteristics of storage media.
Milk as storage media.
After replantation, the treatment of choice is splinting [2]. By definition, splinting is an assembly to protect, stabilize, and immobilize loosened, fractured, replanted, and traumatized teeth [3]. Also splinting is defined by American Association of Endodontists as “a rigid or flexible device or compound used to support, protect, or immobilize teeth that have been loosened, replanted, fractured, or subjected to certain endodontic procedures” [36].
To allow immobilization of the teeth during the initial period, it is mandatory using the so-called splint which is essential for the repair of periodontal ligament [37]. The use of semirigid splint is more indicated than the rigid one, considering that the long period of splinting is not recommended due to its expected complications namely substitutive resorption or ankylosis [38, 39]. One of the adverse healing outcomes of splinting is that forceful placement of the splint may cause additional trauma to the already affected pulp of the avulsed tooth [40].
Many different splinting techniques have been described [41]:
Wire-composite splint, orthodontic splint, titanium trauma splint (TTS) splint, resin splint, Kevlar/fiberglass splint (fiberglass), self-etching and bonding material, and suture splint.
Kahler et al. also described splint types [42]:
Composite and wire splints.
Composite and fishing line splints.
Orthodontic wire and bracket splint 0.3–0.4 mm in diameter.
Fiber splints (polyethylene or Kevlar fiber mesh).
Titanium trauma splint (TTS).
Arch bar splints.
Wire ligature splints.
Composite splints.
Orthodontic brackets and arches.
Wire and composite splints.
Fiber splints.
Titanium trauma splints (TTS).
In cases of associated alveolar or jawbone fracture, a more rigid splint is indicated and should be left in place for about 4 weeks.
Cap splints and orthodontic bands were associated with a greater frequency of pulp necrosis and pulp canal obliteration when compared with acid etch resin splints and no splinting [44].
These splinting techniques were used prior to the development of a passively
applied acid etch resin technique and are no longer recommended [20]
according to the recent guidline, 2020 [20].
Stabilize the tooth for 2 weeks using a passive flexible splint such as wire of a diameter up to 0.016″ or 0.4 mm bonded to the tooth and adjacent teeth. Keep the composite and bonding agents away from the gingival tissues and proximal areas. Second option is nylon fishing line (0.13–0.25 mm) which can be used to create a flexible splint, using composite to bond it to the teeth. Nylon (fishing line) splints are not recommended for children with mixed dentition, since the status of the other teeth may result in instability or loss of such splint.
Tooth-supporting tissue injuries and lip injuries may be associated with avulsion [45].
Soft tissue tearing of the socket gingiva associated with avulsed tooth should be noted [46].
There are three benefits may be gained from the tight stitching of such tearing [47]:
Stop of the bleeding.
Avoid the penetration of microorganism into periodontium.
Allow the primary healing of the wound.
In addition to the soft tissue, the socket itself needs to be manipulated before replantation of the root, if the alveolar bone has collapsed, attempts should be made to reconstruct its wall [48].
It is mandatory to initiate root canal treatment within 2 weeks of tooth replantation [20, 22]. Root canal treatment should start with intracanal medication; calcium hydroxide or antibiotic-corticosteroid paste dressing for 2 weeks up to 1 month or 6 weeks [49, 50] is followed by root canal filling.
No root canal treatment is performed at first, but a close follow-up is needed to detect any clinical or radiographic signs of pulp necrosis. The aim is to re-establish blood supply of open apices and maintain root development which could happen spontaneously after replantation.
Radiographic and clinical examination is indicted after 2 weeks, 4 weeks, 6–8 weeks, 3 months, 6 months, 1 year, and yearly thereafter for at least 5 years. If there is any sign of external infection-related root resorption, endodontics intervention is advised whether it is apexification, root canal treatment, or regenerative endodontic procedures (REPs) [20, 22, 48].
REPs have been proposed based on translational studies. In 2016, American Association of Endodontists and European Society of Endodontology have proposed clinical considerations and position statement; respectively, discussing REPs [51]. In avulsion injuries, REPs are only indicated in cases of immature root with open apex and signs of pulp necrosis. The clinical protocol is the same that have been proposed previously in the mentioned guidelines. A recent report implemented this approach to treat avulsed tooth and showed successful outcome with a 30-month follow-up [52]. The key is using biocompatible materials that would recruit stem cells to build hard tissue barriers and allow physiological growth of roots. Biocompatible materials could be MTA or tricalcium silicate cements, e.g. bioceramicsm that revealed successful outcomes in several reports [53].
Antibiotics given at the time of replantation to prevent the infection may occur due to tooth contamination or may be present in the storage media. Also, it can be prescribed prior to endodontic treatment. It is theoretically effective in preventing bacterial invasion of the necrotic pulp and; further, it may prevent the inflammatory resorption (Figure 7) [54].
Adjunctive therapies in the treatment of avulsed tooth.
In all cases, appropriate dosage for the patient’s age and weight should be calculated.
Amoxicillin or penicillin remains the first choice due to their effectiveness on oral flora and low incidence of side effects. Alternative antibiotics should be considered for patients with an allergy to penicillin [55].
The effectiveness of tetracycline administered immediately after avulsion and replantation has been demonstrated in animal study [56, 57]. Specifically, doxycycline is an appropriate antibiotic to use because of its antimicrobial, anti-inflammatory, and anti-resorptive effects. But still doxycycline exerted no effect on the occurrence of complete pulp revascularization in replanted teeth [58]. Tetracycline or doxycycline is generally not recommended for patients under 12 years of age to avoid the risk of discoloration of permanent teeth [20, 56, 57].
By searching the literature so far, there are some indications of antibiotic prescribed for the patient with avulsed tooth (Figure 8).
Replanted tooth with possibly contaminated root and/or storage media [20, 54] for medically compromised patient.
Avulsed tooth with other related trauma [20].
Prevention of sequalae of avulsion-related bacteremia in the susceptible patients [59].
Prevention of inflammatory resorption in cases with necrotic pulp (tetracycline with its antimicrobial and anti-resorptive effect) [58].
Indication of antibiotics in patient with avulsed tooth.
Prescription of analgesic is case-dependent; accordingly, it should be assessed individually. The use of stronger pain killer is unlikely [20, 48].
Chlorhexidine (CHX) is a commonly used antiseptic mouthwash and is available over the counter (OTC); the use of adjunctive short-term of CHX can enhance oral hygiene by managing dental plaque [60].
The recent recommendation is to use a chlorhexidine (0.12%) mouth rinse twice a day for 2 weeks (during the entire period of splinting).
In cases of severe replacement resorption (RR) and ankylosis, decoronation can be considered as an alternative treatment with good clinical outcomes for children and adolescents to the age when an appropriate implant is possible. If carried out at the right time; it helps to preserve the bucco-palatal dimensions of the alveolar bone and at the same time allows for vertical bone growth. This enables for future implant insertion without the need for the costly and invasive procedure of alveolar ridge augmentation. However, this approach still needs solid studies to verify it [61, 62].
Timing of the decoronation is crucial and should be planned for each individual case with regard to the patient’s age, growth intensity, and growth pattern. In young patients, it is advantageous to retain an ankylosed tooth, if possible, to act as a space maintainer. However, it is very necessary to intervene before the effect of infraposition causes significant arrested alveolar bone growth that makes a final prosthetic solution difficult. When ankylosis is diagnosed before the age of 10 years, there is a high risk of severe infraposition, and the tooth should be carefully monitored every 6 months. There is also a risk of severe infraposition during the pubertal growth spurt which varies in time from one person to another and thus needs also careful monitoring [63].
Clinically, the procedure is simple. Under local anesthesia and a full-thickness flap, the crown of the ankylosed tooth is sectioned earlier the cementoenamel junction. The root is cleaned with a K-file and washed with saline, and the canal is allowed to fill with blood and then the flap is repositioned. Subsequently, esthetics is maintained using an adhesive bridge [62].
Autotransplantation of an immature maxillary premolar to replace an ankylosed tooth is considered a highly successful alternative technique and is particularly indicated when crowding requires extraction of a premolar. To achieve pulpal revascularization and successful periodontal healing of the donor tooth, the ideal root should develop to three-fourths of the complete root length. In such cases, the whole root of the ankylosed tooth must be extracted, and a premolar will be transplanted in its place. The transplant tooth with its sound periodontal ligament will induce new bone formation, have continued root development, and even maintain its vitality. An esthetic restoration and orthodontic treatment will follow the transplant [64, 65].
The long-term prognosis of replanted avulsed teeth shows great variability; the observed outcomes are greatly heterogeneous ranging from healing without symptoms to inflammation and rapid tooth loss. Many studies had shown a relatively low survival rate of replanted avulsed teeth, compared to other types of traumata, ranging from 50% to 83.3% [66]. Under favorable conditions, replanted teeth may be retained for 5 or 10 years and even few of them for a lifetime. However, some may fail very soon after replantation.
Delayed replantation
Unphysiological storage
Teeth with open apices
After replantation of the tooth, the prognosis commonly remains uncertain. Replacement resorption and inflammatory resorption are probable adverse outcomes in comparison with the more favorable functional healing (FH): [66]
The damaged tissues including the cementum and dentin are being resorbed by multinuclear giant cells. In regions with minor damage, the ruptured periodontal fibers are being rebuilt (regeneration). In case of small resorption cavities, the denuded root surface is being recolonized by neighboring cementoblasts and these deposit the cementum in which the new periodontal fibers are anchored. This process represents healing with physiologic function (functional healing, FH) [66, 67].
Root surfaces affected by the trauma are quickly colonized by multinuclear giant cells. If these cells are continuously stimulated by microbial products from an infected root canal, not adequately treated, infection-related resorption (IRR, formerly named inflammatory resorption) will result. Provided the tooth is still restorable, adequate endodontic treatment might stop the progression of IRR.
Replacement root resorption (ankylosis).
Replacement resorption is a special form of root resorption, and it follows serious luxation or avulsion injury. It is a common sequela of delayed replantation and/or dry storage. Due to excessive drying before replantation, the damaged periodontal ligament cells will start an inflammatory response over extended areas on the root surface. The resulting large resorption cavities may not be entirely covered by the cementoblasts in time. Regenerating alveolar bone will be attached directly onto the root surface. In time, through physiologic bone remodeling, the root cementum and dentin will be replaced by bone; a process termed replacement resorption (RR) or ankylosis-related root resorption [65, 66, 67].
If revascularization does not occur or appropriate endodontic therapy is not performed after tooth replantation, pulpal necrosis will occur. The combination of microbes in the root canal and the external surface of the root results in aggressive resorption and can lead to rapid tooth loss [20, 65].
In a growing patient and/or tooth with open apices, the ankylosed tooth shows severe and progressive infraocclusion. The alveolar bone will stop advancing in a coronal direction with the rest of the jaw leaving a big bone defect when the tooth is eventually lost causing major esthetic and functional challenges when it is time for the final replacement [48, 67].
Mature replanted teeth need clinical and radiographic monitoring at 2 weeks (with splint removal), 4 weeks, 3 months, 6 months, 1 year, and hence yearly for at least 5 years. For teeth with open apices where spontaneous pulp revascularization might occur, clinical and radiographic monitoring should be more frequent due to the high risk of infection-related (inflammatory) and/or ankylosis-related (replacement) root resorption. Therefore, replanted teeth with open apices should have clinical and radiographic monitoring at 2 weeks (with splint removal), 1 month, 2 months, 3 months, 6 months, 1 year, and hence yearly for at least 5 years [20].
Evaluation may include the following outcomes:
The replanted tooth is
Asymptomatic, functional,
normal mobility,
no sensitivity to percussion,
normal percussion sound,
no radiolucencies and no radiographic evidence of root resorption. The lamina dura appears normal.
In addition, for teeth with open apices, radiographic evidence of continued root formation and tooth eruption.
Pulp canal obliteration is expected and can be recognized radiographically sometime during the first year after the trauma.
Patient may or may not have symptoms.
Presence of swelling or sinus tract.
The tooth may have excessive mobility or no mobility (ankylosis) with high-pitched (metallic) percussion sound.
In case of open apex, if there is ankylosis, the tooth may gradually become infrapositioned.
Presence of radiolucencies.
Radiographic evidence of infection-related (inflammatory) resorption, ankylosis-related (replacement) resorption, or both.
Or absence of continued root formation (in case of open apex).
When ankylosis occurs in a growing patient, infraposition of the tooth is highly likely to create disturbances in alveolar and facial growth over the short, medium, and long term.
A relatively recent meta-analysis showed trauma of primary dentition to be as common as 22.7% [68] with variable prevalence of avulsion from 7 to 13% [69]. In general, avulsed primary teeth should not be replanted (according to the recommendations of the IADT) [19]. Nevertheless, there are case reports with varying degrees of success after replantation of primary teeth, whereas others reported negative results to the replanted primary tooth and its permanent successor. One systematic review concluded that here is a lack of high-quality studies to support this approach [69].
Such a severe injury to the primary tooth may have negative impact on the development and/or eruption of its permanent successor. Premature loss of avulsed primary teeth might sometimes lead to space loss, masticatory, speech, and esthetic problems; this may also cause negative impact on their behavior, pschological, and social well-being. Removable or fixed appliances present valid treatment options to minimize space loss and improve esthetics when necessary. Furthermore, movement of the tooth during avulsion and the proximity between the primary tooth and the germ of its developing successor may interfere with its further growth and maturation leading to the occurrence of enamel defects and tooth malformations. The risk of sequelae in the permanent successor after avulsion of primary teeth is higher when the injury occurs in young children (<2 years), when the trauma is of greater magnitude such as when more teeth are involved and lower jaw is affected [70, 71].
Sequelae to the permanent successor include (Figure 10) [70]:
Malformations
crown dilaceration,
root dilaceration,
root angulation,
root duplication,
odontoma-like malformation,
arrest of root formation,
sequestration of the permanent tooth germ.
Enamel defects
white/cream or yellow/brown demarcated opacities,
diffuse patchy opacities.,
hypoplasia,
combinations of these.
Delayed eruption
Combinations
Sequelae of primary tooth avulsion.
Teledentistry can be used to monitor those traumatic injuries cases remotely. Teledentistry combines dentistry and telecommunications simultaneously with clinical information and images over remote distances for dental consultation and treatment planning [72].
In cases of traumatic injuries and avulsions specifically, initial emergency instructions could be delivered on phones till obtaining emergency healthcare services is possible. This helps in calming patients or patients’ guardians and maintains the first actions of replanting teeth or storing it in proper storage medium according to the recommendations. Teledentistry is also used at times of follow-up to report symptoms or other complications. It is mainly essential when specialty dentist is not available, yet their consultation, supervision, and valuable support could be used by the dental team in managing such cases [73]. A report showed that around 60% of patients contacted the telemedical center during the so-called “out of office hours” for dental trauma injuries. This percentage signifies the importance of having proper teledental channels addressing these incidents.
Tooth avulsion is the complete displacement of the tooth from its socket in the dental arch.
In this chapter, we tried to gather the scattered information about tooth avulsion. Despite the rich published literature, but still a lot of researches are needed to reach evidence-based conclusions.
Although the tooth avulsion is the topic of concern in general dentistry, we tried to write this perceived paper in the specialist’s manner to reflect more light on many related details.
Causes of tooth avulsion are divided into those for deciduous dentition and other for permanent dentition which are differ from each in their pattern and severity of the trauma [11, 12, 13, 14, 15, 16, 17].
Epidemiology has shown a reduction of cases during COVID-19 era. This was explained by patients’ perceived fear of acquiring viral infections and thus hesitancy to reach out to emergency centers [8, 9, 10].
Avulsion treatment outcomes are very dependent on the first-aid measure as well as the agility to seek dental treatment.
For the management, put it as two phases may let the whole picture organized and well determined by specific time (at the time of trauma) the first phase and the other which are at the clinic.
The storage media (milk, HBSS, saliva, or saline) are discussed in detail regarding the characteristic of each. Nevertheless, researches are still looking for an ideal medium; some materials such as propolis and egg white are very promising. However, the quality of evidence is considered low [74]; on the other hand, teeth splinting is discussed generally as well as specifically for the avulsed teeth (with and without alveolar bone fracture) [20].
The literature regarding the adjunctive therapies for the teeth avulsion showed the role of these therapies; in this chapter, we considered them concisely with stress upon the indications for each [19, 20, 48, 60].
Criteria of successful treatment is widely discussed which is depending on both clinical and radiographic features.
Alternative treatments for the avulsed tooth in cases of the failure of aforementioned treatment are decoronation, autotransplantation, partial prosthesis, and dental implant [61, 62, 63, 64, 65].
The key of optimum outcomes in avulsions cases rely on both radiographical and clinical follow-ups. This signifies the importance of teledentistry and its role in addressing such incidents [72].
The main adverse outcome of tooth replantation is replacement root resorption (ankylosis). It implies possible risks of infraocclusion, impairment of alveolar bone growth, and tooth loss. The risk increases dramatically with delayed replantation [20].
Tooth avulsion is one of few emergencies in dentistry; prevalence differs from area to area according to the cause and gender. Replantation, immediate or delayed is the treatment of choice for the avulsed permanent tooth still immediate and proper replantation is important for long term good prognosis. Many factors may determine the outcome and use of antibiotic; although it is questionable, it is indicated in certain conditions. Although there is no strong evidence for their effect on healing, storage media is one of the factors for the preservation of the vitality of the tooth. It is used according to its availability at the trauma site. There are two stages in the treatment: emergency treatment and definitive treatment; even so, there is no grantee for the success of the treatment. Any avulsed tooth may be followed by complications, either immediately or lately. Despite the recommendation for the manager of the avulsed teeth, still not all recommendation can be applied for every avulsed tooth. Accordingly, any tooth has got special related factors which would determine the treatment plan after studying them carefully.
As a result, immediate and proper replantation is important for long-term good prognosis.
The authors declare no conflict of interest.
IADT | International Association of Dental Traumatology |
FH | functional healing |
IRR | inflammatory root resorption |
RR | replacement resorption |
PPE | personal protective equipment |
HBSS | Hanks’ Balanced Salt Solution |
PDL | periodontal ligament |
AGPs | aerosol-generating procedures |
SAT | systemic antibiotic therapy |
CHX | chlorohexidine |
OTC | over counterpart |
TTS | titanium trauma splints |
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\n\nMetadata for all publications is also automatically deposited in IntechOpen's OAI repository, making them available through the Open Access Infrastructure for Research in Europe's (OpenAIRE) search interface further establishing our compliance.
\n\nIn other words, publishing with IntechOpen guarantees compliance.
\n\nRead more about Open Access in Horizon 2020 here.
\n\nWhich scientific publication to choose?
\n\nWhen choosing a publication, Horizon 2020 grant recipients are encouraged to provide open access to various types of scientific publications including monographs, edited books and conference proceedings.
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He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:{name:"Association for Computing Machinery",country:{name:"United States of America"}}},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). 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He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. 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Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. 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He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. 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He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. 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