|Year : 2013 | Volume
| Issue : 3 | Page : 181-184
Esthetic management of a rare combination of dental trauma with a multidisciplinary approach: A case report
Naman Sharma1, Amit Yadav1, Neeta Shetty1, Sarvesh Agrawal2, M Ashok3
1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India
2 Department of Orthodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India
3 Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India
|Date of Web Publication||21-Apr-2014|
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A combination traumatic injury involving avulsion and intrusive luxation type of injury is a rare clinical occurrence. This case report describes the management of an intruded central incisor along with repositioned avulsed teeth. The rationale behind this interdisciplinary treatment approach was to use orthodontic extrusion of the tooth for biological repositioning of the tooth along with esthetic management during the treatment period.
Clinical Relevance to Interdisciplinary Dentistry
- Avulsed teeth when replanted immediately have a good prognosis.
- Orthodontic extrusion is a viable treatment option in cases of intrusion and subgingival fractures. It is conservative treatment with an extremely favorable prognosis.
- Management of traumatic injury requires a multidisciplinary approach.
Keywords: Avulsion, esthetics, intrusion, orthodontic extrusion, trauma
|How to cite this article:|
Sharma N, Yadav A, Shetty N, Agrawal S, Ashok M. Esthetic management of a rare combination of dental trauma with a multidisciplinary approach: A case report. J Interdiscip Dentistry 2013;3:181-4
|How to cite this URL:|
Sharma N, Yadav A, Shetty N, Agrawal S, Ashok M. Esthetic management of a rare combination of dental trauma with a multidisciplinary approach: A case report. J Interdiscip Dentistry [serial online] 2013 [cited 2020 Aug 5];3:181-4. Available from: http://www.jidonline.com/text.asp?2013/3/3/181/131222
| Introduction|| |
Traumatic injuries to anterior teeth may manifest as various types of luxation injuries or avulsion of teeth. Apart from the physical damage, such injuries also create a psychological impact on the patient, especially when the injury affects permanent dentition and there is extensive loss of tooth structure.  Immediate restoration of esthetics may be the primary concern of the patient, and therefore the clinician has to consider immediate replacement of the missing tooth structure to restore the esthetics, along with improving the function and phonetics.
Tooth avulsion is an infrequent injury, seen in 0.5 to 16% of traumatic injuries. Maxillary central incisors are the teeth most commonly involved, and it usually involves a single tooth.  Multiple tooth avulsion is uncommon and might be sometimes seen in severe injury due to road traffic accidents, sporting activities, domestic violence, and assaults in developmentally disabled individuals.  Replantation of the avulsed tooth can be done in cases where the tooth can be retrieved, in a fairly intact condition and has been either replanted immediately or has been carried in a proper transport medium. 
Intrusive luxation is also a rare type of injury, comprising 3% of all injuries to permanent teeth. It is usually associated with complications like pulp necrosis, inflammatory root resorption, loss of alveolar bone support, and ankylosis. These complications can be avoided by early endodontic treatment.  To regain the normal position of an intruded tooth, various treatment methods that have been suggested are: waiting for spontaneous re-eruption, surgical repositioning, orthodontic extrusion, and a combination of surgical and orthodontic therapy in cases of severe intrusion. ,
The combination of avulsion and intrusive luxation type of injury occurring concomitantly is very rare. Andreason has studied the association between different types of injury to teeth and found that of 40 intrusively luxated teeth, no associated teeth were observed to have avulsed, while of 196 avulsed teeth, no teeth had been intrusively luxated.  The reason for the uncommon occurrence of such type of combination injury can be the different mechanisms of injury associated with these two types of trauma. Intrusive luxation is the result of a direct impact on the incisal edge along the long axis of the tooth,  whereas avulsion of a tooth results from a blunt impact to the tooth associated with high resilience of the tooth supporting structures.
The present case report describes the management of a rare combination of traumatic dental injury, involving intrusion of 11 and avulsion of 12, 21, and 22. The case report also describes a modified technique for orthodontic extrusion which restores the esthetics immediately and is therefore more readily acceptable by the patient.
| Case Report|| |
A 22-year-old male patient presented to the Department of Endodontics, for the treatment of intruded maxillary central incisor following a bicycle accident. On presentation, the maxillary right central incisor was intruded and had a complicated crown fracture involving enamel, dentine, and pulp. History revealed that the trauma had occurred 4 weeks back. Following trauma, maxillary right lateral incisor and the maxillary left central and lateral incisors were avulsed and the right central incisor was fractured and intruded. The patient was treated in a trauma center where the avulsed teeth were replanted back and were splinted for 4 weeks. After the removal of splint, the patient was referred to our department for management of intruded maxillary right central incisor [Figure 1]a.
|Figure 1: (a) Preoperative picture showing complicated crown fracture and intrusion wrt 11(b) composite resin build up for immediate esthetics (c) orthodontic bracket and arch wire bonded for extrusion(d) elastic thread engaged for extrusion(e) Immediate post operative picture(f) 1 year follow-up|
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On intra oral examination, it was found that there was no mobility with respect to the replanted teeth. Percussion tone was normal. Radiographs revealed that the maxillary right central incisor was intruded by approximately 4 mm [Figure 2]a. Sensibility test was negative with respect to all the four anteriors. The treatment options given to the patient for the management of 11 were:1) orthodontic extrusion followed by post-core and crown, 2) surgical repositioning followed by post-core and crown, and 3) extraction followed by replacement with fixed partial denture or implant prosthesis. The advantages, disadvantages, treatment cost and time required for each of the treatment options were discussed with the patient, following which he opted for orthodontic extrusion.
Endodontic treatment was initiated wrt 12, 11, 21, and 22. After access cavity preparation, working length was determined using an electronic apex locator (Propex II, Dentsply, Maillefer, Ballaigues, Switzerland), and was confirmed radiographically. Root canal shaping was done for 11 with hand k files (Dentsply, Maillefer, Ballaigues, Switzerland), MAF was ISO size 60, and for 12, 21, and 22 with rotary protaper file (Dentsply, Maillefer, Ballaigues, Switzerland), up to size f3. Root canal cleaning was done with alternate irrigation using 5.25% NaOCl and saline. Final irrigation was done with 2% chlorhexidine. Following this, 11 was obturated using AH plus sealer (Dentsply, Maillefer, Ballaigues, Switzerland) and gutta percha (Dentsply, Maillefer, Ballaigues, Switzerland) using cold lateral compaction technique [Figure 2]c. Calcium hydroxide (Calcicur, VOCO, Cuxhaven, Germany) was placed as an intracanal medicament in the root canals of 12, 21, and 22 the access cavities were sealed with temporary restoration. Since the patient's main concern was esthetics, a composite resin build up was done for 11 [Figure 1]b.
|Figure 2: (a and b) Preoperative radiographs(c) root canal treatment completed for 11(d) After orthodontic extrusion(e) completion of root canal treatment for 12, 21, and 22(f) 1-year follow-up radiograph|
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An orthodontic bracket was bonded on the labial surface of 11 to facilitate extrusion. A stainless steel orthodontic wire was shaped according to the arch form to extend from the first premolar of one side to the first premolar of the other side. Offset bends and loop was incorporated into the wire corresponding to 11. The wire was bonded on the labial surfaces of all the teeth from 14 to 24 except 11 using composite resin buttons [Figure 1]c. Orthodontic force was applied with the help of a medium elastic thread (TP elastic cotton, Libral Traders Pvt. Ltd., New Delhi, India) engaged to the bracket and loop. 4 mm of extrusion was achieved over a period of 2 months [Figure 2]d. The incisal edge was trimmed sequentially during this period to match the incisal edge of the adjacent central incisor. At this stage, root canal treatment wrt 12, 21 and 22 were completed and the access cavities were sealed with resin composite [Figure 2]e 11 was restored with a fiber post (Reforpost No. 3, Angelus, Londrina, Brazil) and a composite resin core build up. Porcelain fused to metal crowns was given wrt 12, 11, 21, and 22 to provide good esthetics [Figure 1]e. At 1-year follow-up appointment, the teeth were periodontally healthy. No relapse had occurred and the follow-up radiograph did not show any signs of root resorption or ankylosis [Figure 1]f and [Figure 2]f.
| Discussion|| |
Traumatic injuries of anterior teeth involving considerable loss of tooth structure is associated with esthetic, psychological, and functional problems.  The importance of multidisciplinary approach for the management of traumatic injuries cannot be overemphasized. The present case also involves emergency management of trauma in a trauma center, followed by definitive management involving orthodontic, endodontic, and prosthodontic intervention.
In the case described above, the intruded tooth was extruded to regain sufficient amount of supragingival tooth structure. Intrusive luxation is often associated with pulpal necrosis and therefore root canal therapy is anticipated.  Since the intruded tooth had a complicated fracture involving the pulp and isolation of the tooth was possible, therefore a single visit root canal treatment was performed. Waiting for spontaneous re-eruption of the tooth is not advisable in cases of severe intrusion. Lack of eruption during the waiting period is associated with a number of problems including pulp necrosis, root resorption, and ankylosis.  Hence, spontaneous re-eruption was not considered as a treatment option. Surgical repositioning of the tooth is an invasive procedure. It leaves the repositioned tooth with lack of supporting tissues and an undesirable esthetic outcome. It is also associated with periodontal pocket and incidence of root resorption. 
Orthodontic tooth movement is a more biological way of repositioning an intruded tooth. It has the advantage of a more favorable crown root ratio as compared to surgical repositioning of intruded tooth.  The effectiveness of orthodontic extrusion depends on the severity of intrusion and mobility of the tooth soon after the injury. Less severely intruded and slightly mobile tooth respond well to orthodontic extrusion, while the severely intruded tooth with lack of clinical mobility might not respond favorably to orthodontic extrusion.  The timing of initiating the orthodontic extrusion is also important. During orthodontic extrusion, a cooling off period has been suggested to reduce collateral damage.  In this case, the patient presented for management of intrusion 4 weeks after the injury, so orthodontic extrusion was initiated immediately after root canal treatment. In a traumatic injury where one tooth is fractured or luxated, the adjacent may also have suffered injury to some extent. Hence, anchorage should be taken from at least 2-3 healthy teeth.  Since all the four anterior teeth were affected by the injury, anchorage for extrusion was extended up to the premolars on either side.
The most common technique used for orthodontic extrusion of an endodontically treated tooth is using a post cemented inside the root canal. , The biggest disadvantage of this technique is compromised esthetics through the period of extrusion which can extend up to 8 weeks. Composite resin reconstruction of the tooth in this case [Figure 1]b) brought about immediate improvement in esthetics. As the extrusion progressed, the incisal edge was trimmed to prevent any interference of tooth movement and also to maintain the esthetics. The esthetics was further enhanced by the use of composite buttons instead of metallic brackets on the adjacent teeth. A slow extrusion of 4mm was achieved over a period of 2 months; this gives more favorable results as compared to fast orthodontic extrusion. 
Immediate replantation and semi rigid splinting of an avulsed tooth result in a favorable prognosis.  In this case, the avulsed teeth were replanted immediately and were splinted for a period of 4 weeks. Following an avulsion injury, both the pulp and periodontal ligament suffer extensive damage. It is generally agreed that following an avulsion in a tooth with fully formed root, the root canal treatment should be initiated to prevent outcomes like inflammatory resorption and ankylosis.  Timing of initiation of root canal treatment is also important; it has been found that immediate extirpation of the pulp can be detrimental to the long-term prognosis of periodontal ligament.  In the present case, root canal treatment was initiated after 4 weeks of semi-rigid splinting. Use of Calcium hydroxide is recommended as an intracanal medicament in avulsed tooth to prevent external root resorption. 
| Conclusion|| |
The mechanism involved in the combined occurrence of intrusion and avulsion is intriguing. Management of traumatic injuries requires a multidisciplinary approach. The present case involves a combined orthodontic, endodontic, and prosthodontic treatment; a multidisciplinary approach resulted in a favorable outcome. Immediate esthetics of the intruded tooth was restored using a combined orthodontic and restorative approach, which involved composite resin reconstruction of the intruded tooth. Orthodontic extrusion is a conservative treatment with a favorable prognosis and can be considered as an option for the management of intrusion, coronal, or root fractures.
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[Figure 1], [Figure 2]