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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 121-124

Esthetic rehabilitation of intrusive luxation injury: A multidisciplinary approach


Department of Conservative Dentistry and Endodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu, India

Date of Submission16-Oct-2022
Date of Acceptance23-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Manavalan Madhana Madhubala
Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Ramapuram, Chennai - 600 089, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_24_22

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   Abstract 


A 21-year-old male patient reported a chief complaint of a highly placed upper front tooth following a road traffic accident. Clinical examination revealed mild edema on the upper lip and intrusive luxation injury of the maxillary left central incisor. Radiographs showed 8 mm of intrusion without any root fractures. Orthodontic extrusion was initiated, and the tooth was engaged using stainless steel ligature, and activated by 2 mm. Precision was done 3 weeks before debonding to prevent relapse. Debonding was carried out 6 months poststrap up. An endodontic procedure was initiated and calcium-hydroxide dressing was placed as an intracanal medicament for 2 weeks. Obturation was done using gutta-percha and bioceramic sealer followed by postendodontic management with all-ceramic crowns. The patient is under periodic follow-up.

Keywords: Extrusion, intrusion, luxation, orthodontic movement


How to cite this article:
Rao P D, Hoque T, Madhubala MM, Amirtharaj L V, Duraisamy S, Mahalaxmi S. Esthetic rehabilitation of intrusive luxation injury: A multidisciplinary approach. J Interdiscip Dentistry 2022;12:121-4

How to cite this URL:
Rao P D, Hoque T, Madhubala MM, Amirtharaj L V, Duraisamy S, Mahalaxmi S. Esthetic rehabilitation of intrusive luxation injury: A multidisciplinary approach. J Interdiscip Dentistry [serial online] 2022 [cited 2023 Feb 5];12:121-4. Available from: https://www.jidonline.com/text.asp?2022/12/3/121/365610




   Clinical Relevance to Interdisciplinary Dentistry Top


  • The management of intrusive luxation definitely involves endodontic, periodontic, orthodontic, and prosthodontic treatment strategies to bring the best outcome on rehabilitation of the traumatized tooth.



   Introduction Top


Traumatic injury is one of the most important emergency management in the dental office. These injuries have a significant psychological impact on patients who needs timely and efficient therapy to restore the form and function of the traumatized tooth. The prevalence of traumatic injuries in primary dentition is approximately 30%, and in permanent dentition, it ranges to about 20%.[1] However, the intrusion has a prevalence rate of only about 0.3%–1.9% in permanent dentition.[2] Intrusive luxation injury (ILI) can be defined as the axial displacement of the tooth into the alveolar socket. It occurs on the application of axial force causing substantial damage to the pulp and periodontal ligament.[3] Moreover, this type of injury usually presents with a comminuted alveolar fracture and it is considered one of the most complicated and difficult to treat among periodontal ligament injuries.

The sequelae of ILI can range from marginal bone loss, obliteration of the pulp canal space, pulpal necrosis, inflammatory root resorption, ankylosis, and disruption of root development.[4] Most of these consequences can be managed by timely endodontic therapy with periodic calcium hydroxide (CH) intracanal medicament (ICM) to prevent ankylosis and severe root resorption, both of which have guarded prognoses. Before employing treatment strategies, complete examination including the amount of lateral displacement, fracture of the cortical plates, severity of intrusion, general health of the patient, and type of dentition need to be carefully assessed.

According to various literature evidence, the management modalities of ILI can be broadly classified into immediate treatment comprising digital manipulation, spontaneous re-eruption, and surgical repositioning and fixation; and delayed treatment which involves initial orthodontic extrusion (OE) followed by surgical, periodontal, and prosthodontic rehabilitations.[2],[5],[6],[7] OE is an orthodontic tooth movement in a coronal direction to modify the tooth positions and/or induce changes within the surrounding bone and soft tissue with a therapeutic purpose.[8] OE involves applying traction forces to all regions of the periodontal ligament to encourage crestal bone apposition. As the connective tissue connects the gingiva to the root, the gingiva follows the root's vertical movement throughout the extrusion process. Similarly, the periodontal ligament connects the alveolus to the root, which is then drawn along the root movement.[9] Hence, the gingival contour and alveolar bone follow the vertical movement of the root, thereby making it one of the most biologic and physiologic treatment modalities. Traumatic injuries such as ILI require a multidisciplinary approach involving endodontic, orthodontic, periodontal, and surgical aspects to restore the structure, function, and esthetics. This case report presents about the management of a patient with severe ILI in the maxillary anterior tooth and highlights the importance of systematic management proposed to reposition and rehabilitate the intruded tooth.


   Case Report Top


A 21-year-old male patient reported to the outpatient department with a chief complaint of a displaced fractured upper front tooth following a road traffic accident. A thorough case history revealed that trauma had taken place a month back and the patient experienced mild pain with a displaced front tooth for which he had taken analgesics without reporting to any dental clinic. On clinical examination, mild edema was noted on the upper lip and upper central left incisor was severely intruded. Only a fractured incisal third of the tooth was exposed in the oral cavity with grade I mobility and tenderness on palpation and percussion. Ellis class II fracture was also noted in tooth 11. Radiographic interpretation confirmed a coronal fracture of the maxillary right central incisor tooth and approximately 8 mm intrusion of the maxillary left central incisor with a fractured incisal edge of the crown with no root fractures. The patient was reassured and treatment was planned with a multidisciplinary approach involving orthodontic, periodontic, endodontic, and prosthodontic disciplines.

After the explanation of treatment protocols to the patient, consent form was obtained before the initiation of treatment. OE was initiated by the maxillary arch strap up which was done using a 0.022 × 0.028 inch slot, McLaughlin, Bennett, Trevisi (MBT) system prescription, stainless steel orthodontic brackets, and bondable buccal tubes. The archwire sequence used for the alignment of the intruded teeth was 0.014-inch Copper NiTi and 0.016-inch Copper NiTi followed by 0.016-inch stainless steel and 0.018-inch stainless steel (Ormco™). Extrusion of the tooth was achieved by activating the NiTi wire by 2 mm using ligature ties and activation was done every 4 weeks to ensure slow extrusion of the tooth. Alignment of the root was completed with the help of rectangular NiTi and stainless steel archwires. The total orthodontic treatment time was 6 months, following which, pericision or supracrestal fiberotomy was performed using a number 12 curved BP blade. Debonding of the brackets was done 6 months poststrap up.

Once sufficient crown extrusion was achieved as shown in [Figure 1], the tooth was checked for vitality with thermal pulp sensibility tests using Endo-ice (Coltene™) and warm gutta-percha (GP) stick. The tooth was found to be nonvital and slightly tender on percussion. Therefore, nonsurgical endodontic therapy was initiated in the maxillary left central incisor. After adequate isolation with a rubber dam, access opening was performed using a sterile #2 Endo-Access Bur. Working length was determined using a no 35 K-file by Ingle's radiographic technique and reconfirmed using an apex-locator (Root ZX, J Morita™). Cleaning and shaping of the canal were performed using K-files (up to size 55 K-file), and the canal was irrigated with 5.25% of sodium hypochlorite (NaOCl) between each subsequent file size. The canal was thoroughly dried using paper points, and CH ICM (ApexCal, Ivoclar Vivadent™) was placed using a lentulo spiral and subsequently replenished for 2 weeks. Once the tooth was asymptomatic, the canal was finally obturated by lateral condensation method using GP and bioceramic sealer (Nishika Canal Sealer BG, Nippon™). As there was tooth structure loss noted on the palatal surface after extrusion involving the incisal third of the tooth, postendodontic management was carried out using a full-coverage restoration using E. Max. all-ceramic crown). The fractured 11 was directly restored using light-cured composite resin. Periodic clinical and radiographic follow-ups for 2 weeks, 1 month, 3 months, 6 months, and 1 year revealed healthy periodontium without any resorptive defects as shown in [Figure 2].
Figure 1: (a) Pretreatment photograph before initiation of fixed orthodontic therapy. (b) Extrusion of maxillary left central incisor with ligature tie activated. (c) Bonding of MBT in the maxillary arch (occlusal view). (d) Postorthodontic extrusion by 2 mm. MBT: McLaughlin, Bennett, Trevisi system brackets

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Figure 2: (a) Preoperative radiograph, (b) working length radiograph, (c) master cone radiograph, (d) postobturation in, (e) 3 months follow-up, (f) 6 months follow-up, and (g) 1-year follow-up

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   Discussion Top


Trauma to the anterior tooth is the most common casualty among children and in dentition with significant overjet. ILI is one of the most complicated tooth injuries which need efficient treatment planning to have better success rate. Therefore, to bring a promising outcome, a multidisciplinary approach becomes mandatory in the management of this intrusive injury. This case report illustrated some of the many diverse facets of dental trauma which requires sufficient knowledge and combined efforts, to give effective care to the patient.

The treatment strategies for intruded incisors include surgical repositioning, orthodontic eruption, or allowing for spontaneous re-eruption, and is dependent on the stage of tooth development and the degree of intrusion. Surgical repositioning is a rapid treatment approach reserved for the management of deeply impacted teeth due to trauma which may result in pulpal inflammation, marginal bone loss, or ankylosis. Further, the repositioned tooth might be in a mobile state which will certainly require stabilization that can be further challenging. Spontaneous re-eruption avoids damage to the adjacent tissues but may result in inflammatory resorption of the root and subsequent ankylosis and hence should be reserved for cases with a mild intrusion.

As the patient reported around 1 month after the trauma, slow OE was decided, as further spontaneous re-eruption is unlikely to occur. OE allows for the remodeling of the bone and the periodontal apparatus and it can be initiated immediately or can be delayed for few weeks. Delayed OE also reduces the possibility of inflammation to the adjacent structure as it allows adequate healing after trauma. Moreover, rapid extrusion of the teeth with heavy orthodontic force may result in incongruent gingival margins. The ideal orthodontic force used for extrusion used was as low as 35 gms which can be achieved by thermoelastic copper NiTi archwire. These wires exhibit superelastic behavior based on a temperature-related phase transformation to the austenite stage with a transition temperature slightly below oral temperature. The forces exerted by these wires are remarkably low and are recommended for the treatment of patients with periodontal problems.

One of the most common complications of OE of the tooth is relapse. This is mainly attributed to the tension exerted by the dentogingival and alveolar crest fibers and the residual jaw growth.[10] This can be countered using supracrestal fiberotomy, which was performed in this case. The resection of gingival fibers will prevent the gingival margin and bone to follow the tooth movement, thereby preventing relapse and ensuring long-term stability. The external root resorption (replacement resorption) might be one of the complications which might arise in such cases. To arrest the inflammation process, certain measures were taken during endodontic treatment. Placement of CH as an ICM within the root canal was done as it neutralizes the low pH, reduces osteoclastic activity, and stimulates repair.[11] Sheehy et al. reported the formation of an apical barrier with an average time of 5-20 months in traumatized permanent teeth on placing CH dressing with a success rate of 74%-100%.[12] Heward et al. showed better hydroxyl ion diffusion through dentin by measuring pH change at the 2-week interval with the intracanal placement of mineral trioxide aggregate or CH which can be useful in arresting the resorptive process.[13] Bioceramic sealer was originally intended for both pulpal and bone regeneration. It is available as two paste system which contains fatty acids, bismuth subcarbonate, silica dioxide (Paste A), magnesium oxide, calcium silicate glass, and silica dioxide (Paste B). It exhibits excellent biocompatibility and radiopacity. Bioceramic sealers were selected for this case as exhibit high pH, calcium ion release, and root strengthening potential, which could arrest root resorption and promote periapical healing.[14] Finally, an all-ceramic full-coverage crown was given to mask the discoloration and to correct the proclination of the tooth for providing better esthetics. The traumatized tooth was subjected to orthodontic forces which could be prone to future resorptive defects. Hence, nonvital bleaching was not advocated to manage the discoloration defect which might accelerate the resorptive process.

The limitation of this type of extrusive management lies in the longer treatment period and the patient follow-up. However, it is proposed to be the most conservative procedure for preserving the biological width, the periodontium for natural bone remodeling in cases of ILI. In the present case, there was a high degree of intrusion which needed a multidisciplinary approach to yield satisfactory esthetic and functional rehabilitation.


   Conclusion Top


Interdisciplinary management focusing on preserving the biological width, periodontium, for natural bone remodeling in cases of severe ILI can prevent posttraumatic complications. This case report highlights the prompt and efficient management skills of such clinical cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Andersson L. Epidemiology of traumatic dental injuries. J Endod 2013;39:S2-5.  Back to cited text no. 1
    
2.
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. 2
    
3.
Eriksen HM. Endodontology – Epidemiologic considerations. Endod Dent Traumatol 1991;7:189-95.  Back to cited text no. 3
    
4.
Medeiros RB, Mucha JN. Immediate versus late orthodontic extrusion of traumatically intruded teeth. Dent Traumatol 2009;25:380-5.  Back to cited text no. 4
    
5.
Sapir S, Mamber E, Slutzky-Goldberg I, Fuks AB. A novel multidisciplinary approach for the treatment of an intruded immature permanent incisor. Pediatr Dent 2004;26:421-5.  Back to cited text no. 5
    
6.
Turley PK, Crawford LB, Carrington KW. Traumatically intruded teeth. Angle Orthod 1987;57:234-44.  Back to cited text no. 6
    
7.
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. 7
    
8.
González-Martín O, Solano-Hernandez B, González-Martín A, Avila-Ortiz G. Orthodontic extrusion: Guidelines for contemporary clinical practice. Int J Periodontics Restorative Dent 2020;40:667-76.  Back to cited text no. 8
    
9.
Bach N, Baylard JF, Voyer R. Orthodontic extrusion: Periodontal considerations and applications. J Can Dent Assoc 2004;70:775-80.  Back to cited text no. 9
    
10.
Castaño Duque SP, Mora Díaz II, Losada Amaya SI, Álvarez Gómez LM, Rengifo Mosquera LM, Zerpa Romandini Á, et al. Orthodontic treatment stability and periodontal condition with circumferential supracrestal fiberotomy: A systematic review. Rev Fac Odontol Univ Antioq 2019;31:122-35.  Back to cited text no. 10
    
11.
Dumsha T, Hovland EJ. Evaluation of long-term calcium hydroxide treatment in avulsed teeth – An in vivo study. Int Endod J 1995;28:7-11.  Back to cited text no. 11
    
12.
Sheehy EC, Roberts GJ. Use of calcium hydroxide for apical barrier formation and healing in non-vital immature permanent teeth: A review. Br Dent J 1997;183:241-6.  Back to cited text no. 12
    
13.
Heward S, Sedgley CM. Effects of intracanal mineral trioxide aggregate and calcium hydroxide during four weeks on pH changes in simulated root surface resorption defects: An in vitro study using matched pairs of human teeth. J Endod 2011;37:40-4.  Back to cited text no. 13
    
14.
Dudeja C, Taneja S, Kumari M, Singh N. An in vitro comparison of effect on fracture strength, pH and calcium ion diffusion from various biomimetic materials when used for repair of simulated root resorption defects. J Conserv Dent 2015;18:279-83.  Back to cited text no. 14
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