|Year : 2020 | Volume
| Issue : 3 | Page : 154-159
Delayed surgical repositioning of severely intruded permanent maxillary central incisor with completely formed root: A case report with narrative review and a decision/intervention flowchart based on the International Association of Dental Traumatology guidelines
Boris Saha1, Sharique Alam1, Surendra Kumar Mishra1, Md Kalim Ansari2
1 Department of Conservative Dentistry and Endodontics, Dr. Z.A. Dental College, A.M.U, Aligarh, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Dr. Z.A. Dental College, A.M.U, Aligarh, Uttar Pradesh, India
|Date of Submission||09-Feb-2020|
|Date of Decision||13-Mar-2020|
|Date of Acceptance||14-Jun-2020|
|Date of Web Publication||28-Oct-2020|
Dr. Sharique Alam
Department of Conservative Dentistry and Endodontics, Dr. Z.A. Dental College, A.M.U, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Intrusive luxation is a severe dental injury and may result in complicated healing sequelae. Management and prognosis of these injuries depend on the factors such as severity of intrusion, stage of root development, and time elapsed between injury and treatment intervention. The aim of this article is to report the management of severe intrusion injury in an adult patient with mature apices who had delayed seeking treatment by 7 days. Three-year follow-up of the patient has shown successful radiographic and clinical outcomes in spite of limiting prognostic factors. This article also reviews the literature regarding current treatment protocols and summarizes the management strategy employed in the present case in a decision/intervention flowchart.
Keywords: Dental trauma, intrusion, luxation, splint, surgical extrusion
|How to cite this article:|
Saha B, Alam S, Mishra SK, Ansari MK. Delayed surgical repositioning of severely intruded permanent maxillary central incisor with completely formed root: A case report with narrative review and a decision/intervention flowchart based on the International Association of Dental Traumatology guidelines. Endodontology 2020;32:154-9
|How to cite this URL:|
Saha B, Alam S, Mishra SK, Ansari MK. Delayed surgical repositioning of severely intruded permanent maxillary central incisor with completely formed root: A case report with narrative review and a decision/intervention flowchart based on the International Association of Dental Traumatology guidelines. Endodontology [serial online] 2020 [cited 2020 Nov 28];32:154-9. Available from: https://www.endodontologyonweb.org/text.asp?2020/32/3/154/299282
| Introduction|| |
Intrusive luxation are relatively uncommon dental traumatic injury corresponding to only 0.5%–2% of all traumatic injuries in permanent teeth  and 5%–12% of dental luxations., Intrusive luxation is defined as the apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing periodontal ligament, and commonly causes crushing fracture of alveolar socket. This traumatic injury is therefore associated with serious damage to pulp and supporting periodontium and is considered the severest luxation injury to affect permanent teeth.
Pulp necrosis, radicular inflammatory resorption, dentoalveolar ankylosis, loss of marginal bone support, calcification of pulp tissue, paralysis or disturbance of radicular development, and gingival retraction may occur as consequence of an intrusive luxation., Teeth with mature root apices, severe intrusion injury, and treatment delay between time of injury and seeking treatment are associated with the higher incidence of adverse healing sequelae. Treatment must factor clinical prognostic determinants and take into account means to mitigate or eliminate occurrence of undesirable sequelae.
There is no consensus in the literature for the ideal treatment of traumatically intruded permanent teeth. Waiting for spontaneous re-eruption is indicated for immature permanent teeth because of their high potential for eruption and pulp/periodontal repair., For intruded teeth with closed root apices, repositioning must be done by surgical manipulation or application of orthodontic forces.
This article describes the management of a severely intruded (>7 mm) permanent central incisor with closed root apices in which surgical repositioning was delayed by seven days post injury. This article also reviews the literature regarding current treatment perspective for managing intrusion injury in permanent dentition.
| Case Report|| |
A 38-year-old male patient reported with an intruded maxillary right central incisor following a fall from stairs. He was initially taken to a medical hospital in his locality where his medical investigation was done, and his fall from stairs was recorded in his medical prescription as a hypoglycemic episode. He subsequently reported seven days after the traumatic injury to the Department of Conservative Dentistry and Endodontics to seek treatment for his dental trauma. His medical history revealed that he had Insulin-Dependent Diabetes Mellitus for 25 years and was currently taking insulin 20 IU in the morning and 15 IU at the night. Swelling of upper lip could be observed during extraoral examination.
Intraoral examination revealed swollen upper lip, gingival swelling, inflammation, and bleeding from gingival sulcus of intruded maxillary right central incisor. There was 7.0–8.0 mm intrusion [Figure 1]. The tooth was nearly firm in the socket and was tender on palpation and percussion. Maxillary left central incisor was also found to be tender to percussion.
Intraoral periapical radiograph was carefully examined to elicit relevant details. Root of maxillary right central incisor was completely formed with the incisal edge of the intruded tooth located at cervical third of adjacent tooth crown. Periodontal ligament space around right maxillary central incisor was indistinct. Maxillary occlusal radiograph revealed the root of maxillary right central incisor to be displaced palatally [Figure 2].
|Figure 2: Top left to right: Initial periapical and occlusal radiographs showing intruded and palatally displaced roots of maxillary right central incisor Bottom Left to Right: 1 year and 3 year follow-up radiographs showing no adverse radiographic sequelae|
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Local anesthesia was administered, and intruded tooth was teased and manipulated with gentle force with extraction forceps [Figure 3]. Adhesion around the tooth was severed as gently as possible while repositioning the tooth to its normal incisal level [Figure 4]. Splinting was done with composite and fiber splint (Interlig, Angelus) from canine to canine for four weeks [Figure 5]. The splinted tooth was kept out of occlusion. Antibiotic (amoxicillin 500 mg, three times a day for 5 days), analgesics, and mouth rinse (0.2% chlorhexidine gluconate) were prescribed. The patient was instructed not to bite with his anterior teeth and was emphasised importance of home care and follow-up visits in contributing to better healing outcomes.
|Figure 3: Surgical Repositioning of intruded maxillary right central incisor by gentle manipulation with extraction forceps|
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|Figure 4: Immediate postoperative clinical appearance after repositioning the intruded teeth to its correct incisal level|
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|Figure 5: Surgical repositioned intruded maxillary right central incisor was splinted with a nonrigid fiber splint (Interlig, Angelus) for 4 weeks|
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After 10 days, the upper lip soft-tissue swelling had subsided, and restored level of central incisor was confirmed. Pulp sensitivity was evaluated on the recall visit (10 days after the first visit). Electric pulp test and cold test elicited negative response in maxillary right central incisor. Contralateral maxillary left central incisor along with all other maxillary anterior teeth elicited positive response.
The likelihood of pulp necrosis in teeth with mature apices suffering from a severe intrusive luxation (>7 mm) is extremely high. Necrotic infected pulp in association with damaged external root surface due to the intrusive injury can result in the rapid progression of inflammatory root resorption. A decision to undertake the root canal treatment was therefore made.
Endodontic intervention was initiated on right central incisor. After administering local anesthesia, access cavity was prepared. Apical patency was established with #15 K File (Dentsply, Maillefer, Switzerland), and working length was determined with apex locator (Root ZX, J. Morita, Tokyo, Japan) and confirmed radiographically. Root canal was prepared to master apical size of 50 K file. Flaring of the canals was done by the step-back technique. Recapitulation was performed during stepping up cycle, and canals were copiously irrigated with alternate rinse of 3% sodium hypochlorite (Percan: Septodent) and normal saline. After completion of biomechanical preparation freshly prepared paste of calcium hydroxide (Sultan, Fenix, NJ) in saline was placed with the aid of lentulospiral for 1 month.
Fiber splint was removed after four weeks during which tooth had stabilized at the correct level. However, the patient complained of slight discomfort on palpation of periapex mucosa of maxillary right central incisor. A decision for extended calcium hydroxide dressing was taken keeping in perspective existing clinical symptoms as well as the risk for subsequent development of external inflammatory root resorption. The existing calcium hydroxide paste was changed with dense mix of calcium hydroxide with saline which was replaced every three months until the root canal was obturated with gutta percha. During each follow-up visit, pulp vitality test of adjacent maxillary anterior teeth elicited positive response and did not show any signs of pulpal necrosis. Radiographic and clinical evaluation was also carried out to detect any negative sequelae in traumatically injured and adjacent anterior teeth. The tooth was obturated after ascertaining no sequelae of root resorption one year after the initial visit [Figure 2].
At three-year recall, gingival margin of repositioned right central incisor was located more apically than the left central incisor [Figure 6]. The intruded tooth was clinically asymptomatic, with healthy surrounding periodontal tissue, no signs of root resorption or loss of marginal bone support [Figure 2]. A summary of the case is presented in [Table 1].
|Figure 6: Clinical appearance on 3-year follow-up reveals healthy surrounding periodontium. Gingival level of repositioned maxillary right central incisor can be appreciated to be located apically than the adjacent left central incisor|
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|Table 1: Brief flowchart for clinical evaluation, investigation and clinical intervention|
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| Discussion|| |
Intrusive luxation causes severe injury to attachment apparatus and disrupts apical vasculature to dental pulp often leading to ischemia of the pulpal and periodontal tissues.,, It is recommended to treat dental intrusions within the first 24 h. Treatment delay may increase the risk of healing complications. In the present case, permanent maxillary central incisor was severely intruded and had been left untreated for 7 days, and hence poor/guarded prognosis was anticipated and communicated to the patient.
Treatment options for repositioning intruded permanent teeth with completely formed root
The International Association of Dental Traumatology (IADT) guidelines  lays down the following strategies to treat intrusive luxation injuries in permanent teeth with complete root formation:
- Allow eruption without intervention if tooth is intruded <3 mm. If no movement after two to four weeks, reposition surgically or orthodontically before ankylosis can develop
- If tooth is intruded 3–7 mm, reposition surgically or orthodontically
- If tooth is intruded beyond 7 mm, reposition surgically.
Surgical repositioning: Weighing treatment options in severe intrusion injury
Severely intruded teeth do not have functional periodontal ligament. Traction forces therefore applied to move intruded teeth are higher than in conventional orthodontic treatment and may not offer any advantage of preserving periodontal ligament in severe intrusion injury.
Immediate surgical repositioning was suggested by Skieller. According to Ebeleseder et al., advantage of the surgical technique is that it can be easily performed; it returns adjacent tissues to original anatomic situation to allow repair and also facilitates initiating fast and adequate endodontic access. However, exarticulation during repositioning can induce additional damage to periodontal ligament and increase the incidence of ankylosis, pulp necrosis, and marginal bone loss. The disadvantages of surgical procedure would depend on professional's care and skill than on the procedure itself.
In this case, surgical repositioning was chosen as treatment modality based on the IADT recommendation for intrusion >7 mm. Current evidence, however, suggests no clear preference of any one treatment over the other.
Splinting type and duration
Current evidence supports short-term, nonrigid splinting for luxated teeth. A nonrigid splint can stabilize traumatized teeth, while allowing physiological tooth movement. In this case, a flexible fiber splint was employed for 4 weeks based on the IADT guidelines. Acid etch-bonded splints allow good oral hygiene and are well tolerated by patients. Splint was placed on buccal surface of maxillary teeth to enable lingual endodontic access and to avoid occlusal interference.
Intrusive luxation leads to pulp necrosis in 96.0% cases of teeth with completely formed roots and is an inadvertent sequelae. Pulpal infection, following injury to precementum or predentin, may stimulate inflammatory resorption with the osteoclastic activity in periradicular tissues or pulp. Endodontic intervention with intracanal medicament should begin two to three weeks after repositioning teeth with mature apices, before pulpal necrosis with bacterial contamination is established. In the present case, it was initiated in the second visit which was 10 days after the initial visit.
Amongst the root canal dressing, calcium hydroxide has shown success in arresting inflammatory resorption., According to Cvek, calcium hydroxide should be maintained for 1–6 months before obturation. While the ideal duration of calcium hydroxide has not been established longer duration has been advocated in traumatically injured teeth with immature root apices to achieve apexification or in patients with signs of root resorption. Long term calcium hydroxide can weaken root dentin which is a concern in immature teeth having thin dentin support. In traumatically injured teeth with mature apices and no adverse healing sequelae one month of calcium hydroxide has often been advocated. Longer duration of calcium hydroxide application in these cases can be carried out in compliant patients to monitor for periodontal healing and adverse healing sequelae. In the present case there was slight tenderness on palpation of periapex mucosa of intruded tooth on one month recall. Considering severity of intrusive injury, delay in repositioning, medical history of type 1 diabetes, persisting periapex tenderness on one month recall and compliance of patient decision for longer term calcium hydroxide intracanal medicament was taken.
A prudent and pragmatic approach to determine duration of calcium hydroxide would be the radiographic observation of integrity of lamina dura following which decision to complete endodontic treatment can be taken.
Prognostic determinants and adverse sequelae
It was previously believed that stage of root development was the determining prognostic factor for intruded teeth. Currently, amount of intrusion seems to be the most critical factor establishing the survival of pulp and tooth. Intrusions up to 3.0 mm have excellent prognosis, whereas severe intrusion >6.0 mm present with increased occurrence of inflammatory root resorption and pulp necrosis.,
Andreasen advocates that time interval between occurrence of intrusive injury and surgical repositioning is a decisive factor for development of external root resorption. Kinirons and Sutcliffe  observed that retention rate of teeth surgically repositioned >24 h after suffering intrusive injury was significantly lower than where repositioning was not delayed. In this case patient had delayed reporting for dental treatment by 7 days.
The severe intrusion (>7 mm) in permanent teeth with closed apices and delayed reporting for treatment complicates favorable healing and prognosis in this case. However, 3-year follow-up has shown uneventful healing which could be attributed to minimizing damage to periodontium by careful and delicate handling during surgical repositioning as well as patient compliance in following postoperative instructions.
Use of antibiotics
There is limited evidence for the use of systemic antibiotics in luxation injuries. Antibiotic use remains the discretion of clinician as traumatic dental injury is often accompanied by soft tissue and other associated injuries. In addition, the patient's medical status may warrant antibiotic coverage., In the present case, the patient was advised antibiotics due to the persisting soft-tissue swelling of the upper lip and his medical history of diabetes mellitus.
| Outcome and Conclusion|| |
This case report demonstrates the successful management of a severely intruded tooth without any healing complications during three-year evaluation follow-up. Delicate surgical handling and patient compliance might aid long-term retention even in tooth with poor prognostic determinants such as mature root apices, severe intrusion injury, and delay in treatment intervention. However, these results needs to be critically evaluated in light of higher levels of evidence and treatment modalities should be formulated based on emerging scientific evidence together with the clinician's expertise.
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
Conflicts of interest
There are no conflicts of interest.
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