|Year : 2020 | Volume
| Issue : 1 | Page : 69-73
Management of traumatically intruded permanent maxillary central incisors
Nuha S Alghamdi
Department of Restorative Dental Sciences, College of Dentistry, King Khalid University, Saudi Arabia
|Date of Submission||23-Mar-2019|
|Date of Decision||22-Apr-2019|
|Date of Acceptance||14-May-2019|
|Date of Web Publication||27-Dec-2019|
Dr. Nuha S Alghamdi
Department of Restorative Dental Sciences, College of Dentistry, King Khalid University P.O. Box: 1122, Abha
Source of Support: None, Conflict of Interest: None
The management of intrusive luxation varies depending on the patient's age, stage of root development, and severity of the trauma. These kinds of injuries are associated mostly with severe damage to the pulpal tissue, periodontium, and the tooth. The aim of this case report is to present multidisciplinary management of complete intrusion of maxillary central incisors in a 9-year-old healthy girl with external root resorption. The root canals were cleaned and medicated with calcium hydroxide then the teeth were extruded by an orthodontist. After two months, a 4 mm apical plug with mineral trioxide aggregate was placed in the apical third of the canals and the remaining of the canal was obturated with thermoplasticized gutta-percha. Cervical root resorption was noticed during the follow-up evaluation and was surgically managed.
Keywords: Cervical resorption, cone beam computed tomography, external resorption, intrusion, trauma
|How to cite this article:|
Alghamdi NS. Management of traumatically intruded permanent maxillary central incisors. Saudi Endod J 2020;10:69-73
| Introduction|| |
Intrusive luxation is defined as “the displacement of tooth apically into the alveolar bone in the socket, which causes a crushing fracture of alveolar socket and compression of periodontal ligament (PDL).
In permanent dentition, it comprises about 0.3%–1.9% of all traumatic injuries and 6–12-year group is the peak incidence. Healing is complicated in intrusion cases as it presents as the most complex and severe type of injury to dentoalveolar component. The main complication after intrusion is root resorption, pulp necrosis, and periodontal bone healing. These complications are mainly due to various treatment factors such as repositioning method (spontaneous re-eruption, surgical reposition, and orthodontic reposition), delay in commencing treatment, type of splint (rigid, semi-rigid, and flexible), and period of splinting., The treatment for an intruded tooth usually involves either active repositioning (surgical or orthodontic extrusion) or passive, by spontaneous reeruption. The present case aims to report the multidisciplinary management of intruded young permanent central incisors in a 9-year-old patient with 2 years of follow-ups.
| Case Report|| |
A 9-year-old girl was referred by her previous dentist to King Fahad Hospital in Jeddah, Saudi Arabia, for the treatment of his upper central incisors. The patient had a history of fall 1 month back for which he had visited a primary health center hospital in Al Qunfudah area of Saudi Arabia. At that time of trauma, the dentist in the primary health center, after examining the patient advised the parents that the child has intruded his upper central incisors and the teeth will reerupt after some time.
After 1 month, the patient came to the endodontic clinic at King Fahad Hospital. On clinical examination, more than two-third of the upper right (#11) and left (#21) central incisors teeth had re-erupted with more of a buccal proclination [Figure 1]a and [Figure 1]b. The gingiva around the teeth # 11.21 was inflamed. Periapical radiograph was taken. There was the obliteration of the periapical PDL due to compression of periodontal surrounding tissues was caused by apical movement of teeth #11, 21 into the bony socket. In addition, there is radiolucency around the apices of the teeth #11 and 21 and root resorption [Figure 1]c. Electric pulp test (SybronEndo dental model 2006) and cold test in relation to both teeth #11, 21 did not show any responses. Therefore, the pulpal diagnosis for both teeth (#11 and 21) was pulpal necrosis with asymptomatic apical periodontitis and external root resorption. Since teeth #11 and 21 were having a buccal proclination, so the orthodontic consultation was made. The orthodontist recommended an extrusion appliance which was custom made designed by the orthodontist and fabricated in the laboratory, made by 0.032 in stainless steel wire modeled around a transpalatal bar with extrusion arms which will be subsequently followed by fixed appliance. After explaining the treatment procedure to the child's parents, an informed consent was signed.
|Figure 1: Preoperative clinical view (a and b) shows the upper central incisors (#11 and 21) had re-erupted with more of a buccal proclination. The gingiva around the teeth was inflamed. Preoperative periapical radiograph (c) shows radiolucency around the apices of the upper central incisors and multiple areas of root resorption (white arrow)|
Click here to view
After applying topical anesthesia, local anesthesia (lidocaine 2% with adrenaline 1:100,000) was administered through buccal and palatal infiltration. A rubber dam was applied, and access cavity was made in both central incisors. After pulp extirpation, the canals were irrigated with 2.5% sodium hypochlorite (NaOCl) and 2% chlorhexidine. Canals were lightly instrumented, dried with paper point, and filled with an intracanal medicament calcium hydroxide mixed with barium sulfate (META, Korea). The access cavity was closed with glass-ionomer filling (Ketac ™ Fil Plus. 3M, USA).
The patient was referred to orthodontic clinic for orthodontic extrusion. She was recalled after 2 months for reevaluation. The extrusion appliance was constructed by orthodontist [Figure 2]a.
|Figure 2: Clinical view shows the extrusion appliance construction (a). Periapical radiograph shows the obturation of the teeth #11 and 21 with MTA plug and gutta-percha filling the rest of the canals (b)|
Click here to view
After 2 months, the patient presented to the clinic. The teeth were asymptomatic. The rubber dam was applied, and the coronal filling was removed. Canals were irrigated with 5.25% NaOCl. Working length was determined with K-file size 50 by taking an intraoral periapical radiograph and reconfirmed with the use of apex locator (J Morita Root ZX Module, US). Radiographs were taken from different angles to verify the length as the orthodontic metal appliance made it difficult to view the apex. Canals were enlarged to size 80 K-file with copious irrigation with 2.5% NaOCl. A 4 mm apical plug with mineral trioxide aggregate (MTA) (ProRoot ® MTA Dentsply International, Inc., Johnson City, USA) was placed in the apical third of the canals which was confirmed by a radiograph to check it then the remaining of the canal was obturated with thermoplasticized gutta-percha technique using the hotshot device (SybronoEndo, US). A composite restoration (3M ESPE, ST. Paul, USA) was used to fill the access cavity [Figure 2]b.
The patient was recalled after 3 months at the orthodontic clinic for re-evaluation. The orthodontist decided to remove the extrusion appliance and to continue for fixed orthodontics treatment to correct the anterior malocclusion. Follow-up radiograph was taken to evaluate the status of the upper centrals incisors, and it was found that there was a cervical root resorption in the distal wall of tooth #21 [Figure 3]. A cone-beam computed tomography (CBCT) was taken to detect the location and extent of the cervical resorption. The CBCT image showed that the resorptive defect was located at the distal-buccal region (Class 11) Heithersay classification for cervical resorption  [Figure 4]. A surgical approach was decided to remove the resorptive tissue repair it. The surgical procedure was carried out under 50% nitrous oxide sedation.
|Figure 3: Periapical radiograph shows cervical root resorption in the distal wall of tooth #21 after removal of orthodontic appliance|
Click here to view
|Figure 4: The cone beam computed tomography image showed that the resorptive defect to be distal-buccal (Class II) Heithersay classification for cervical resorption (yellow circle)|
Click here to view
Local anesthesia infiltration with 2% lidocaine with 1:100,000 epinephrine and a supplementary intraligament anesthesia on mesial and distal of tooth #21 was given. The brackets were removed. An intersulcular incision was made from tooth #12 to tooth #22 without vertical release. Flap reflected and area exposed and tissue was curetted under modified loops. An aqueous solution of “90% trichloroacetic acid (TAC)” (Tri-Chlor, Gordon, USA) was topically applied in the resorptive cavity then the cavity was restored with Ketac glass ionomer filling, and the tissue was sutured [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d. Sutures were removed after 2 weeks, and the brackets were placed by the orthodontist. The patient was recalled for follow-up after 6 months [Figure 6]a and 2 years [Figure 6]b. She was asymptomatic during this period, and the tooth was functional with no sign of further resorption.
|Figure 6: Follow-up 6 months' postsurgery that reveals the ceasing of the resorptive process (a). Two years after initial treatment. The tooth was functional, and there was no sign of further resorption in the radiograph (b)|
Click here to view
| Discussion|| |
Intrusion luxation injuries have the poorest prognosis of all dental traumas because of significant damage to the pulp, PDL and/or the alveolar bone. Depending on the severity of intrusion and root maturity, the treatment of intruded teeth varies and the best treatment modalities can be as follows:
- Re-eruption by passive repositioning
- Orthodontic repositioning with either a removable or fixed appliance or immediate surgical repositioning.
In this case, only half of the intruded teeth re-erupted spontaneously. Orthodontic repositioning with extrusion appliance was the option chosen for complete re-eruption of the intruded teeth.
Since intrusion leads to loss of vitality of the tooth, root canal treatment is mandatory. The recommended time for initiating root canal treatment in such teeth is approximately 2 weeks after the injury. A nonsetting calcium hydroxide paste dressing was applied inside the canal with touch all canals walls to control root resorption before obturation. When compared to conventional computed tomography, CBCT produces a better-undistorted image with a substantial lower dose of radiation. As it is much more challenging to identify the extent of resorptive defects located onto the labial or palatal aspects of a tooth than mesial and distal aspects with conventional radiographic techniques, CBCT can assess such defects in a better way giving us a precise nature and extent of the lesion.
The effect of intrusion on the PDL such as surface resorption or infection-related and alkalosis-related (replacement) resorption has been identified. Repair-related resorption is a transient process involving small areas on the root surface following luxation injuries. As long as, conditions are right for healing, i.e. the absence of bacteria in the root canal, this type of resorption is reversible. This was noticed in the current case. This case shows a resorptive defect which can be arrested using the Heithersay approach  (i.e., debridement of lesion mechanically, treatment with TAC, and restoration).
The treatment of an external resorptive defect with a chemical agent such as 90% TCA before the curettage of the lesion has been advocated in the past. This was applied in the present case. The advantage of this approach is better hemorrhage control. The resorptive tissue becomes avascular due to coagulation necrosis caused by the effect of TCA. The inactivation of adjacent and potentially resorptive cells by TCA prevents the recurrence of such type of resorption, which is another reason for its utilization. Finally, a resin-modified glass ionomer cement was used to restore the resorptive defect. According to the literature, bone tissue displays an excellent level of tolerance to glass-ionomer cements. Resin-modified glass ionomer cements because of hydrophilic monomers, and photo-initiators have improved physical and mechanical properties.
| Conclusion|| |
Intrusive luxation injuries are mostly associated with severe damage to the pulpal tissue, periodontium, and the tooth. The present case describes the multidisciplinary approach of managing such complex dental injuries which has been recognized as an ideal treatment modality according to the recent literature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
I would like to thank Dr. Suheel Baba for editing the manuscript and Dr. Kholoud Baglaf for the nitrous oxide sedation done for the patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Andreasen FM, Andreasen JO, editors. Luxation injuries. In: Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd
ed. Copenhagen: Munksgaard Publishers; 1994.
Chacko V, Pradhan M. Management of traumatically intruded young permanent tooth with 40-month follow-up. Aust Dent J 2014;59:240-4.
de Alencar AH, Lustosa-Pereira A, de Sousa HA, Figueiredo JH. Intrusive luxation: A case report. Dent Traumatol 2007;23:307-12.
Faria G, Silva RA, Fiori-Júnior M, Nelson-Filho P. Re-eruption of traumatically intruded mature permanent incisor: Case report. Dent Traumatol 2004;20:229-32.
Heithersay GS. Invasive cervical resorption. Endod Topics 2004;7:73-92.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007;23:66-71.
Albadri S, Zaitoun H, Kinirons MJ; British Society of Paediatric Dentistry. UK national clinical guidelines in paediatric dentistry: Treatment of traumatically intruded permanent incisor teeth in children. Int J Paediatr Dent 2010;20 Suppl 1:1-2.
Vahid Golpayegani M, Tadayon N. A multidisciplinary approach to the treatment of traumatically intruded immature incisors. A 6-year follow up. Iran Endod J 2006;1:151-5.
European Commission. Radiation Protection No. 172, Cone Beam CT for Dental and Maxillofacial Radiology, Evidence Based Guidelines. Luxembourg: Directorate-General for Energy Directorate D-Nuclear Energy Unit D4-Radiation Protection; 2012.
Elbay US, Elbay M, Kaya E, Sinanoglu A. Management of an intruded tooth and adjacent tooth showing external resorption as a late complication of dental injury: Three-year follow-up. Case Rep Dent 2015;2015:6.
Trope M. Luxation injuries and external root resorption – Etiology, treatment, and prognosis. J Calif Dent Assoc 2000;28:860-6.
Asgary S, Nosrat A, Fazlyab M: Intra-canal management of a post traumatic perforative invasive cervical root resorption using calcium enriched matrix cement. Saudi Endod J 2013;3:139-43.
Tavares WL, Lopes RC, Oliveira RR, Souza RG, Henriques LC, Ribeiro-Sobrinho AP. Surgical management of invasive cervical resorption using resin-modified glass ionomer cement. Gen Dent 2013;61:e16-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]