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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 72-76

Management of an intruded permanent central incisor with late presentation following trauma


1 Department of Restorative Dentistry, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka
2 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka

Date of Web Publication30-May-2018

Correspondence Address:
Aruna A. A Kumara Wimalarathna
Faculty of Dental Sciences, University of Peradeniya, Peradeniya
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_39_16

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   Abstract 


Most traumatic injuries to the upper permanent incisors result in crown fractures. It is commonly associated with luxation injuries. This report describes a multidisciplinary management of a traumatically intruded permanent central incisor tooth of an 18-year-old boy who presented late after trauma. The intruded tooth had been endodontically treated immediately after the injury while the tooth was in the same intruded position. Five years after the initial injury, the tooth was surgically repositioned and restored with postendodontic therapy with good esthetics.

Keywords: Intrusion, multidisciplinary management, surgical extrusion, traumatic injury


How to cite this article:
Kumara Wimalarathna AA, N. Fonseka MC, S. Jayasuriya NS. Management of an intruded permanent central incisor with late presentation following trauma. J Interdiscip Dentistry 2018;8:72-6

How to cite this URL:
Kumara Wimalarathna AA, N. Fonseka MC, S. Jayasuriya NS. Management of an intruded permanent central incisor with late presentation following trauma. J Interdiscip Dentistry [serial online] 2018 [cited 2020 Jan 24];8:72-6. Available from: http://www.jidonline.com/text.asp?2018/8/2/72/233615




   Clinical Relevance to Interdisciplinary Dentistry Top


  1. Management of traumatic dental injuries with a delayed presentation would require multidisciplinary management in order to achieve a successful outcome.
  2. Late management of intrusion may require orthodontic or surgical reposition in addition to the conventional restorative.



   Introduction Top


Traumatic intrusion is a luxation injury where the tooth is axially displaced into the alveolus. Although intrusive luxation is more common in deciduous teeth, it is considered rare in permanent teeth.[1] Intrusive luxation occurs in severe forms of injuries and accounts to only 3% of all traumatic injuries in permanent dentition.[2] Intrusion injuries are often associated with significant damage to the tooth structure, periodontium, and pulpal tissues. Complications of such injuries include pulp necrosis, inflammatory root resorption, dentoalveolar ankylosis, loss of marginal bone support, calcification of the pulp tissue, paralysis or disturbance of root development, and gingival retraction.[3],[4] Therefore, the treatment plan and the management protocols should be focused on eliminating or minimizing the occurrence of such complications.

Although the optimal treatment for traumatically intruded permanent incisors remains controversial, three treatment approaches have been reported: wait for the spontaneous re-eruption, which is indicated for immature permanent teeth, surgical repositioning, or orthodontic repositioning for mature teeth.[5],[6]

This paper reports the case of a multidisciplinary management of delayed presented traumatically intruded permanent central incisor by surgical repositioning.


   Case Report Top


An 18-year-old male patient, referred from a rural hospital, was reported at the Department of Restorative Dentistry, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka. He had met with a road traffic accident 5 years before and injured his maxillary left central incisor.

The intraoral examination confirmed that the crown of the upper left central incisor (#21) was fractured and the tooth was apically positioned [Figure 1]a. From the history and radiological investigation, it revealed that the intruded tooth was endodontically treated immediately after the injury due to complicated crown fracture while the tooth remained in the same intruded position [Figure 1]b. Thereafter, the patient had defaulted treatment and presented only 5 years later due to personal reasons.
Figure 1: (a) Fractured and apically positioned upper left central incisor (#21) tooth (b) Intraoral periapical radiograph of upper central incisor region

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Clinically, the tooth was diagnosed as an intrusively luxated permanent upper left central incisor (#21) with a complicated crown fracture. Radiographically, the tooth showed severe intrusion (>6 mm) with complete root development [Figure 1]b. Although the right central incisor had a periapical lesion without evidence of any root resorptions, the intruded tooth did not show any signs of periapical pathology with a radiologically acceptable root canal obturation. The radiograph revealed an initial stage of ankylosis with partial loss of lamina dura in the mesial surface of the root. There were no signs of external or internal root resorption. The luxated tooth was not mobile.

Surgical repositioning was selected over orthodontics considering the patient request for an immediate outcome. In addition, the suspicion of ankylosis did not justify the use of orthodontic treatment for extrusion.

Surgical procedure

An envelope flap was raised under local anesthesia on the labial side of upper right central incisor to left lateral incisor after local anesthesia (lignocaine 2% with adrenaline 1:80,000). The full-thickness flap was elevated, and the intruded tooth was visualized. The alveolar bone was prepared at the recipient site and the left upper central incisor was repositioned. The labial aspect of the cortical bone was lost and the root was not covered with bone [Figure 2].
Figure 2: Vestibular flap and the splinter

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The tooth was immobilized in its new position by a 0.6-mm stainless steel wire and light cure composite splint (3M ESPE, Nano-Hybrid Z-250 XT, USA) [Figure 2]. The bone dehiscence on the labial aspect was filled with an alloplastic bone graft (BioGraft-βTCP 500–1000 μm) to cover the exposed root of the surgically extruded tooth [Figure 3]. Subsequently, the bone graft was covered with a collagen membrane (10 mm × 15 mm Colo Gide GTR membrane). The surgical flap was repositioned and sutured to cover the collagen membrane [Figure 4] and [Figure 5]. Antibiotics and analgesics were prescribed for 5 days. Postsurgical instructions were given on eating habits and maintaining of good oral hygiene.
Figure 3: Placement of bone graft

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Figure 4: Placement of collagen membrane

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Figure 5: Immediate postoperative photograph

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The patient was recalled 2 weeks after surgery and the remaining vicryl sutures were removed [Figure 6]. The splint was removed 4 weeks after the surgery, and crown buildup was done with light cure composite (3M ESPE, Nano-Hybrid Z-250 XT, USA) [Figure 7]. On the same visit, internal periapical radiographs were taken which revealed that the repositioned tooth appeared to be short due to change in the angulation of the tooth. Furthermore, it showed disappearance of the peripheral lesion in relation to the upper right central incisor after surgery. As such, endodontic treatment (Re-RCT) was not performed on the upper right central incisor and it was kept under observation [Figure 8]. The follow-up visits were planned at 3, 6, and 12 months and then yearly [Figure 9] and [Figure 10].
Figure 6: Two weeks after the surgery

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Figure 7: Crown buildup with composite after 4 weeks

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Figure 8: Intraoral periapical radiograph of upper central incisor region after 4 weeks

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Figure 9: Three months after the surgery

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Figure 10: Six months after the surgery

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   Discussion Top


One complication of intrusive luxations may be tooth malposition because of treatment delay following the injury.[7] The severity of the intrusion was classified according to the British Society of Paediatric Dentistry reviewed guideline regarding treatment of traumatically intruded permanent incisor teeth in children in 2009. The classification classifies into grades as mild (<3 mm); moderate (3–6 mm); and severe (>6 mm).[1]

Treatment decisions of these teeth are governed by the maturity of the root and the severity of intrusion. The most severe form of intrusive luxation injury, not surprisingly, yields the poorest prognosis and requires more complex treatment.[7]

The ideal treatment for the intruded permanent teeth is contradictory. The clinically recommended treatment options for intruded teeth include allowing spontaneous re-eruption of the tooth; surgical repositioning and fixation; orthodontic repositioning; and periodontal crown lengthening.[7],[8],[9]

According to Andreasen and Andreasen,[4] in the majority of cases, the treatment of choice for traumatically intruded permanent teeth with complete root formation is orthodontics rather than the surgical repositioning. The disadvantages of orthodontic extrusion have been reported as long treatment time and prolonged or permanent retention, strict patient compliance, and higher treatment costs.[3]

Authors such as Calişkan [10] and Ebeleseder et al.[11] have recommended the surgical repositioning as the treatment of choice for intrusive luxations in permanent dentition. Ebeleseder et al.[11] analyzed 58 traumatically intruded and surgically extruded permanent teeth and observed that the greater the manipulation during the surgical repositioning procedures, the higher the incidence of ankylosis. However, the surgical extrusion was not found to have any influence on the loss of alveolar bone support.[11] According to these authors,[11] the advantages of the surgical repositioning include an easily handled treatment approach and replacing the tooth in its original anatomical condition. This yields healing of the supporting tissues as well as endodontic access at the right moment even though it is accepted that total dislocation of the root from the socket during the surgical repositioning procedures may substantially increase the risk for dental ankylosis.[12] Such disadvantages of the surgical procedure depend on the skill of the operator.

Nelson-Filho et al.[12] reported the case of a 10-year-old boy that was referred to the pediatric dentistry clinic 15 days after sustaining a severe traumatism that led to complete intrusion of the maxillary left mature permanent central incisor. The intruded tooth was repositioned by using surgical extrusion. The postoperative course was uncomplicated, with both clinical and radiographic success up to 10 years of follow-up. Therefore, surgical repositioning combined with endodontic therapy constituted a viable alternative treatment for intrusive luxations in mature permanent teeth.

These findings are in agreement with those of the present report, which showed that the treatment approach adopted for the management of an intruded mature permanent central incisor was successful up–to-date (6 months) follow-up. The periapical radiolucency and areas of external inflammatory root resorption were not yet revealed, and the tooth remained in the oral cavity in a good condition. A ceramic crown restoration will be planned in the future for better esthetics.

According to the reported literature, they revealed most of the intruded teeth are managed immediately after the initial injury. However, the gaining of successful outcomes by doing surgical repositioning for severely intruded tooth reported 5 years after the initial injury, as seen in this case report, is exceedingly rare.


   Conclusion Top


Multidisciplinary (endodontics, periodontics, surgeries or orthodontics, and prosthodontics) approach is now recognized as ideal, in the management of complex dental trauma. Early treatment meets the patients' expectations while respecting the biological, functional, and esthetic aspects.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
albadri S, Zaitoun H, Kinirons MJ. Treatment of Traumatically Intruded Permanent Incisor Teeth in Children. BSPD Reviewed Guidelines; August, 2009.  Back to cited text no. 1
    
2.
Andreasen JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 1970;78:329-42.  Back to cited text no. 2
    
3.
Andreasen FM, Pedersen BV. Prognosis of luxated permanent teeth – The development of pulp necrosis. Endod Dent Traumatol 1985;1:207-20.  Back to cited text no. 3
    
4.
Andreasen JO, Andreasen FM. Essentials of Traumatic Injuries to the Teeth: A Step-By-Step Treatment Guide. Copenhagem: Munksgaard; 2000.  Back to cited text no. 4
    
5.
Shapira J, Regev L, Liebfeld H. Re-eruption of completely intruded immature permanent incisors. Endod Dent Traumatol 1986;2:113-6.  Back to cited text no. 5
    
6.
Turley PK, Crawford LB, Carrington KW. Traumatically intruded teeth. Angle Orthod 1987;57:34-44.  Back to cited text no. 6
    
7.
Pandya C, Pandya M, Patel S, Ughareja M. Delayed multidisciplinary management of an intrusively luxated maxillary lateral incisor – A case report. Int J Clin Dent Sci 2011;2:50-2.  Back to cited text no. 7
    
8.
Robertson A, Andreasen FM, Bergenholtz G, Andreasen JO, Norén JG. Incidence of pulp necrosis subsequent to pulp canal obliteration from trauma of permanent incisors. J Endod 1996;22:557-60.  Back to cited text no. 8
    
9.
Mandel U, Viidik A. Effect of splinting on the mechanical and histological properties of the healing periodontal ligament in the velvet monkey (Cercopithecus aethiops). Arch Oral Biol 1989;34:209-17.  Back to cited text no. 9
    
10.
Calişkan MK. Surgical extrusion of a completely intruded permanent incisor. J Endod 1998;24:381-4.  Back to cited text no. 10
    
11.
Ebeleseder KA, Santler G, Glockner K, Hulla H, Pertl C, Quehenberger F, et al. An analysis of 58 traumatically intruded and surgically extruded permanent teeth. Endod Dent Traumatol 2000;16:34-9.  Back to cited text no. 11
    
12.
Nelson-Filho P, Faria G, Assed S, Pardini LC. Surgical repositioning of traumatically intruded permanent incisor: Case report with a 10-year follow up. Dent Traumatol 2006;22:221-5.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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