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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 46-49

Management of traumatically intruded permanent maxillary lateral incisor - Case report and review of literature


1 Department of Periodontology, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Public Health Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
3 Department of Periodontology, Dental Faculty, Jamia Millia Islamia, New Delhi, India

Date of Web Publication1-Jul-2016

Correspondence Address:
Deepak Sharma
Department of Periodontology, Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-4696.185193

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  Abstract 

Primary etiologic factors of trauma in the permanent dentition are bicycle accidents, sports accidents, falls, and fights. From the standpoint of therapy, anatomy, and prognosis, five different types of luxation lesions are recognized: Concussion, subluxation, extrusive luxation, lateral luxation, and intrusive luxation. Intrusive luxation is apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament, and commonly causes a crushing fracture of the alveolar socket. It is considered one of the most severe luxation injuries to affect permanent teeth. Intrusion injuries are often associated with severe damage to the tooth, periodontium, and pulpal tissue. The rare occurrence of this injury, 0.3–1.9% in the permanent dentition, has resulted in limited studies to support suggested treatment regimens. Clinical treatment for intrusion is especially difficult because of the severe complications accompanying it. These complications include pulp necrosis or obliteration, inflammatory root resorption, ankylosis, replacement root resorption, and loss of marginal bone support. Hence, the aim of presenting this case report of intrusive luxation is to highlight the importance of prompt care and root canal dressing and discuss the several treatments proposed to reposition the intruded teeth.

Keywords: Ankylosis, intrusion, root resorption, surgical repositioning, traumatic injury


How to cite this article:
Sharma D, Jhingta P, Bhardwaj VK, Bhardwaj A. Management of traumatically intruded permanent maxillary lateral incisor - Case report and review of literature. J Dent Allied Sci 2016;5:46-9

How to cite this URL:
Sharma D, Jhingta P, Bhardwaj VK, Bhardwaj A. Management of traumatically intruded permanent maxillary lateral incisor - Case report and review of literature. J Dent Allied Sci [serial online] 2016 [cited 2019 Jan 16];5:46-9. Available from: http://www.jdas.in/text.asp?2016/5/1/46/185193


  Introduction Top


Luxation lesions account for 15.0–61.0% of the trauma in permanent teeth. The primary etiologic factors are bicycle accidents, sports accidents, falls, and fights. From the standpoint of the therapy, anatomy, and prognosis, five different types of luxation lesions are recognized: Concussion, subluxation, extrusive luxation, lateral luxation, and intrusive luxation. The factors establishing the type of lesion seem to be the force and direction of the impact.[1]

Intrusive luxation is defined as apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament, and commonly causes a crushing fracture of the alveolar socket.[2] It is considered one of the most severe luxation injuries to affect the permanent teeth. Intrusion injuries are often associated with severe damage to the tooth, periodontium, and pulpal tissue. The rare occurrence of this injury, 0.3–1.9% in the permanent dentition, has resulted in limited studies to support suggested treatment regimens.[3] Clinical treatment for intrusion is especially difficult because of the severe complications accompanying it. These complications include pulp necrosis or obliteration, infl ammatory root resorption, ankylosis, replacement root resorption, and loss of marginal bone support.[4]


  Case Report Top


A 26-year-old female patient reported with an intruded maxillary right lateral incisor following a fall from the stairs 2 h ago. Her medical history was noncontributory. Bruising on the upper lip could be observed in extraoral examination. Intraoral examination revealed lacerated upper lip, gingival inflammation, and bleeding from gingival sulcus of the incisors. There was 5.0–6.0 mm intrusion of the maxillary right permanent lateral incisor and had Grade II mobility [Figure 1]. The radiographic examination showed intrusion of the maxillary right permanent lateral incisor and complete root formation, and the incisal edge of the intruded tooth was located at the mid half level of the crown of the adjacent teeth. Root of the maxillary right central incisor was also displaced mesially. Furthermore, periodontal ligament space was absent in lateral incisor [Figure 2]. Local anesthesia was administered, and intruded tooth was manipulated with gentle force with sterile plastic instrument. The tooth was brought to normal incisal level. Splinting was done with composite and wire splint from canine to canine at a new restored level for 2 weeks. The splinted tooth was kept out of occlusion. Tetanus injection was administered at the same appointment. Antibiotic was prescribed (amoxicillin 500 mg, three times and a day) for 5 days. Analgesics and mouth rinse (0.2% chlorhexidine gluconate solution) were also recommended. She was instructed not to bite with her anterior teeth and was encouraged to maintain good oral hygiene. Her follow-up visits were also scheduled. After 15 days, the swelling had subsided, and new restored level of lateral incisor was confirmed. As the teeth can be in a state of shock initially after trauma, pulp sensitivity was evaluated only after 15 days on maxillary anteriors. Maxillary right central and lateral incisor was found to be negative to the test. Endodontic intervention was performed on the right central and lateral incisor. Root canal was prepared, and a calcium hydroxide-based root canal dressing was applied for 2 weeks. As teeth became asymptomatic, the teeth were finally obturated with gutta-percha and root canal sealer. The patient was scheduled for every 6-month follow-ups.
Figure 1: Intruded maxillary right permanent lateral incisor

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Figure 2: Absence of periodontal ligament in lateral incisor

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At 6-month recall, both teeth were clinically asymptomatic and in function with healthy surrounding periodontal tissues [Figure 3]. No loss of marginal bone support, pathologic mobility, and periapical tenderness was observed. Radiographic examination revealed integrity of the lamina dura and external root resorption in the apical third of the root of maxillary lateral incisor [Figure 4]. At 1 year, the teeth presented aspects of normality clinically and nonprogressing root resorption radiographically [Figure 5].
Figure 3: Six-month recall showing functionally and healthy surrounding periodontal tissues

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Figure 4: Integrity of the lamina dura and external root resorption in the apical third of the root of maxillary lateral incisor

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Figure 5: One-year posttreatment: Nonprogressing root resorption radiographically

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  Discussion Top


One of the most damaging injuries to a tooth and its supporting structures is an intrusion luxation. These injuries are often accompanied by comminution or fracture of the alveolar socket. The low incidence of intrusion injuries may explain the paucity of knowledge about treatment of these cases.[1] Decisions regarding the treatment vary according to the severity of intrusion and whether the tooth has a complete or incomplete root formation.[1],[3] In the present case, the root formation was complete, and treatment was planned accordingly. A thorough medical and dental history was obtained together with details of how, when, and where the accident occurred. A large degree of force is required to severely intrude permanent incisor teeth. Therefore, one should be alert to the possibility of other injuries including injuries to the head and facial region. In the established dentition, diagnosis is based on the difference in the position of the incisal edges of the affected and unaffected teeth, whereas in the mixed dentition, a high metallic note on percussion is indicative of intrusion or lateral luxation.[5] As a routine, for radiographic examination, several projections and angles are recommended; (1) 90° horizontal angle, with central beam through the tooth in question, (2) occlusal view, (3) lateral view from the mesial or distal aspect of the tooth in question.[6] This may reveal differences in apical levels, alveolar fractures or signs of damage to adjacent teeth, and absence of periodontal ligament space from all or part of the root.[5],[6] However, in this case, only 90° horizontal angle, with central beam through the teeth was taken.

In the management of intrusive luxation, extra- and intra-oral lacerations and wounds should be cleaned and sutured as appropriate. Systemic antibiotic treatment and tetanus boosting may be required if external contamination has occurred. Decisions regarding treatment may vary according to the maturity of the root and severity of the intrusion. The possible treatment modalities are as follows:

  • Passive repositioning, to allow the tooth to re-erupt
  • Active repositioning including immediate surgical repositioning (SR) or orthodontic repositioning (OR) using removable or fixed appliances.[5]


After thorough debridement of extraoral and intraoral injuries, immediate SR was done as the patient was not willing for any orthodontic treatment. The UK national clinical guidelines,[2],[5],[7] related to this issue, suggest spontaneous re-eruption for the management of mildly intruded teeth (<3 mm) with incomplete apex. The relative merits of orthodontic repositioning or spontaneous re-eruption of mildly intruded teeth with complete apex are unproven, and treatment choice is by personal preference. Moderately intruded teeth (3–6 mm) with incomplete apex can be repositioned either by orthodontic force or spontaneous re-eruption. Treatment choice is by clinical judgment and preference. Moderately intruded teeth with complete apex should be repositioned orthodontically. In the cases of severely intruded teeth (>6 mm) with incomplete apex, the alveolus is grossly dilated labially and occasionally is fractured. There is often severe soft tissue displacement, and the crown may be completely buried. Hence, consideration should be given to SR of the tooth. Severely intruded teeth with complete apex need to be repositioned surgically, and appropriate tissue repair should be carried out as was done in this case. The difficulty in orthodontic repositioning of severely intruded teeth is the reason of suggestion for SR.[7]

Intruded teeth that are surgically repositioned require appropriate splinting. A nonrigid (flexible) splint should be used to stabilize the traumatized teeth, while allowing physiological tooth movement. The choice of splint depends on the facilities available and clinical situation (e.g. patient in mixed dentition stage, multiple tooth injuries). The splinted tooth should be out of traumatic occlusion. In all cases, the tooth should be reviewed within 1 week of the accident to assess the healing process. Although Andreasen et al. recommend a splinting period of 6–8 weeks following SR, a shorter period of 10 days also has been shown to permit sufficient reduction in mobility to allow function.[5]

In any case, root canal treatment is a must, and ankylosis-related resorption is a frequent occurrence as was also evident in the present case.[8] The recommended time to start root canal treatment in teeth with complete root development is approximately 2 weeks after the injury. In cases of severe intrusion, this early endodontic therapy is facilitated by rapid SR. In the presence of inflammatory root resorption; the canal should be dressed with nonsetting calcium hydroxide paste with appropriate replacement until root resorption is controlled before obturation.[5] The value of repositioning from a theoretical point of view may relieve compression zones in periodontal and pulpal area and thereby facilitate healing. Second, the creation of distance between root surface and contused bone socket may favor cemental healing instead of ankylosis.[8]

The benefit of systemic antibiotic treatment in relation to pulpal or periodontal healing is unproven. Nevertheless, the use of antibiotic is governed by clinical judgment (e.g., contamination, associated hard, and soft tissue injuries).[5] The choice between orthodontic or SR remains an area of debate. In those teeth with complete root development and severe intrusion (>6 mm), SR will allow access to start root canal treatment. Andreasen et al.[3] favored SR of moderate to severely intruded teeth with complete root development as it is potentially less time-consuming and requires fewer patient visits.[5]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andreasen FM, Andreasen JO, editors. Luxation injuries. In: Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. Copenhagen: Munksgaard Publishers; 1994.  Back to cited text no. 1
    
2.
Pacheco L, Filho P, Letra A, Menezes R, Villoria G, Ferreira S. Evaluation of the knowledge of the treatment of avulsions in elementary school teachers in Rio de Janeiro, Brazil. Dental Traumatol 2003;19:76-8.  Back to cited text no. 2
    
3.
Andreasen JO, Bakland LK, Matras RC, Andreasen FM. Traumatic intrusion of permanent teeth. Part 1. An epidemiological study of 216 intruded permanent teeth. Dent Traumatol 2006;22:83-9.  Back to cited text no. 3
    
4.
de Alencar AH, Lustosa-Pereira A, de Sousa HA, Figueiredo JH. Intrusive luxation: A case report. Dent Traumatol 2007;23:307-12.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
    
6.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007;23:66-71.  Back to cited text no. 6
    
7.
Kinirons MJ. UK national clinical guidelines in paediatric dentistry: Treatment of traumatically intruded permanent incisor teeth in children. Int J Paediatr Dent 1998;8:165-8.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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