Decoronation of an ankylosed tooth for preservation of alveolar bone prior to implant placement*

Abstract – A 12‐year‐old patient sustained avulsions of both permanent maxillary central incisors. Subsequently, both teeth developed replacement resorption. The left incisor was extracted alio loco. The right incisor was treated by decoronation (removal of crown and pulp, but preservation of the root substance). Comparison of both sites demonstrated complete preservation of the height and width of the alveolar bone at the decoronation site, whereas the tooth extraction site showed considerable bone loss. In addition, some vertical bone apposition was found on top of the decoronated root. Decoronation is a simple and safe surgical procedure for preservation of alveolar bone prior to implant placement. It must be considered as a treatment option for teeth affected by replacement resorption if tooth transplantation is not feasible.     

Successful minimally invasive management of primary maxillary central incisors after lateral luxation: a case report

Lateral luxation in primary maxillary incisors is a traumatic injury that can lead to darkening of the tooth, pulp necrosis, root resorption, and damage to the permanent teeth. Management of this kind of trauma typically includes pulpectomy or extraction in cases of root resorption. However, in young children, removal of the tooth may be psychological stressing, especially for the parents, while increased mobility can make immediate endodontic treatment difficult to perform. This article outlines a severe palatal luxation on the maxillary right central incisor treated with conservative management in a 2-year-old boy. At the one-year follow-up appointment, the surrounding bone was healthy, the roots displayed physiological resorption, the crowns showed color improvement, and there was no radiographically noticeable damage to the permanent teeth.     

Treatment of aggressive external root resorption with calcium hydroxide medicaments: a case report

Abstract –  Intrusive luxation is an injury involving the axial displacement of a tooth into the alveolar socket. This paper describes apexification using calcium hydroxide medicaments of an immature permanent central incisor in which spontaneous re-eruption as well as severe inflammatory external root resorption was observed following traumatic intrusion. A 10-year-old boy was referred to the Department of Pediatric Dentistry 3 days after having fallen at school. Intraoral examination revealed intrusive luxation and an enamel-dentin crown fracture of the maxillary left central incisor (Tooth 21). The tooth was not sensitive to percussion and responded positively to electric pulp test. Radiographic examination indicated that the tooth had an open apex and had been intruded approximately 3–4 mm relative to the cemento-enamel junction of the adjacent right central incisor. The tooth was left for possible spontaneous re-eruption. The crown fracture was temporarily restored using glass ionomer cement, and the patient was scheduled for recall in 2 weeks, at which time intraoral examination revealed spontaneous re-eruption of the tooth. However, radiographic examination also showed inflammatory external root resorption. The root canal was accessed and filled with a calcium hydroxide paste; however, follow-up examination indicated continuing resorption after 1 month. Calcium hydroxide plus points (CHPP) was chosen as an alternative treatment. At the end of 6 months of CHPP treatment, examination showed no further progression of external resorption and complete apexification of the tooth. After a 24-month follow-up period, no signs of pathosis were observed.     

Conservative treatment of an ankylosed tooth after delayed replantation: a case report

Abstract –  An 8-year-old boy sustained avulsion of his upper right maxillary central incisor and lateral luxation of his upper left maxillary incisors. Subsequently, the upper right maxillary central incisor developed replacement resorption, and both upper left maxillary incisors developed pulpal canal obliteration. In the ankylosed tooth, decoronation procedure was performed, and in the 44-month follow-up period the involved alveolar site showed vertical apposition of bone and continuing replacement resorption. Decoronation is a surgical procedure that allows preservation of the bone volume for the future, avoiding aesthetic disturbances and more aggressive treatments in cases where other therapeutic alternatives are not feasible.     

Reattachment of anterior teeth fragments using a modified Simonsen’s technique after dental trauma: report of a case

Abstract – This is a case report of a 9‐year‐old boy with complicated crown fractures of two traumatized teeth: left maxillary central and lateral incisors. The central incisor presented a small pulpal exposure of approximately 1 mm and the lateral incisor had an ulcerated and exposed pulp. Endodontic management included direct pulp capping, partial pulpotomy, and restorative management including reattachment of the teeth fragments using a modified Simonsen’s technique. The reattached fragments were assessed clinically and radiographically at 12 months. The teeth remained vital, there were no color changes, and the restorations had an acceptable appearance.     

Conservative treatment of a cervical horizontal root fracture and a complicated crown fracture: a case report

Abstract This case report describes successful long-term conservative management of a cervical root fracture and a complicated crown fracture of the maxillary central incisors in a 12-year-old patient. A mineral trioxide aggregate partial pulpotomy was performed on the maxillary right central incisor, while the maxillary left central incisor was splinted to the neighbouring lateral incisor using an acid-etch technique. Both teeth remained asymptomatic throughout the 3.5 years of a review period, with the cervical root fracture having mostly healed with the formation of a calcified tissue between the fragments. Two different treatment methods were used for two different injuries that resulted in pulp preservation in both cases. This in turn has provided for normal root development to occur while also allowing for preservation of bone.     

Replantation of three avulsed permanent incisors with complicated crown fractures

AIM: To report a rare case of multiple avulsions of permanent teeth associated with complicated crown fractures. SUMMARY: The case describes a 3-year follow-up of the treatment of three avulsed maxillary incisors with complicated crown fractures. The teeth were replanted after an extra-oral time of 90 min (extra-oral dry time 6 min). After root canal treatment, the fractured maxillary incisors were restored with a layered hybrid composite material to re-establish aesthetics and function. Follow-up visits showed signs of replacement resorption affecting the maxillary central incisors but only minor signs of root resorption on the maxillary right lateral incisor. These findings were supported by digital volume tomography, which was performed 18 and 36 months post-trauma in order to assess extent, severity and progression of root resorption more accurately. *Healing of avulsed teeth depends on the degree of periodontal ligament (PDL) damage. *Digital volume tomography might improve diagnostics of root resorption.     

The multidisciplinary management of a fused maxillary central incisor with a talon cusp

Background: A fused maxillary incisor required complex multidisciplinary treatment to preserve health and restore aesthetics. This report presents a rare case of a dental fusion between the maxillary right central incisor and a supernumerary tooth of a 9‐year‐old male patient with the chief complaint of the presence of a large anterior tooth. Methods: Radiographic investigation and computerized tomography indicated there was no connection between pulp chambers. After dividing the crown with a diamond bur, the supernumerary tooth was removed and the diastema between the maxillary central incisors was closed by orthodontic treatment. The tooth was then restored with composite resin. Results: The maxillary right central incisor was still healthy after a follow‐up examination period of 24 months. Conclusions: A multidisciplinary approach with the cooperation of different practitioners can contribute to the success of a treatment plan.     

Multidisciplinary solution for an avulsed upper central incisor: case report

Abstract – This case report refers to an 18‐year‐old female who suffered from dental trauma when she was 7 years old caused by a bicycle accident. Her maxillary right central incisor was avulsed, and the left one was extrusively luxated. The left central incisor was correctly repositioned and immobilized with a semi‐rigid splint. The right one could not be found. She presented with class II malocclusion and severe negative arch‐length discrepancies in both arches. The treatment objectives were the following: recover smile esthetics by replacing the maxillary right central incisor, correct the class II relationship, and optimally reduce mandibular and maxillary crowding. Extractions of the maxillary left lateral incisor and the lower right first bicuspid were performed; thus, the maxillary right lateral incisor would function as a maxillary right central incisor, the canines would function as lateral incisors, and the first bicuspids would function as canines. This allowed for the malocclusion to be corrected while simultaneously reestablishing the smile esthetics, without the use of an osseointegrated implant. A good occlusion with coincident upper and lower midlines was achieved. After orthodontic therapy, the patient underwent periodontal surgery to improve her gingival margins. Subsequent teeth bleaching was performed, and the patient received six porcelain veneers. A combination of orthodontic space closure and prosthetic rehabilitation may be the best treatment option after severe traumatic tooth loss.     

Vital pulp therapy of mandibular incisors: a case report with 11-year follow up

This report describes a case of a young patient in whom all the mandibular incisor teeth suffered complicated crown fractures because of a car accident. For all mandibular incisors, pulpotomy with calcium hydroxide were performed in order to achieve apexogenesis and the teeth were restored with a double-seal of glass ionomer cement and composite resin. The patient was reviewed over 11 years. All the mandibular incisor teeth showed continued root development and complete apex formation. Pulp canal obliteration was observed in only the mandibular right central incisor.     

Evaluation of pulpal blood flow after tooth splinting of luxated permanent maxillary incisors

Abstract –  Laser Doppler flowmetry (LDF) is a non-invasive method to assess pulpal blood flow (PBF). Dental injury has been associated with losses of pulpal sensibility. The purpose of this study was to assess whether LDF could be used to detect short- and long-term changes of PBF values of luxated permanent maxillary central incisors after repositioning and splinting. In 18 trauma patients, a single maxillary incisor treated by repositioning and splinting, and the respective contralateral homologous tooth were investigated by LDF to assess local PBF values. Perfusion units (PU) were taken in four sessions: on the day of splint removal, and 12, 24, and 36 weeks after splint removal. Analysis of the luxation type-related PBF measurements revealed intrusion type-related PBF values to be associated with a significant decrease in PBF values ( P  < 0.05), while lateral luxation and extrusion type-related PBF values showed no significant difference between the session-related values ( P  > 0.05). PBF measurements did not change over time for the contralateral incisors ( P  > 0.05). Teeth affected by an intrusion-type luxation injury remained unresponsive to sensitivity testing at follow up, while 3 (60%) developed grey discoloration of the crown. LDF may become useful in the detection of ischemic episodes of luxated maxillary central incisors after repositioning and splinting. Further studies are warranted to assess the validity of post-traumatic 'ischemic episodes' by comparing it to histological tooth pulp changes.     

Revascularization of immature permanent incisors after severe extrusive luxation injury

Pulp necrosis is an uncommon sequel to extrusive luxation in immature teeth with incomplete apical closure. In this report, we describe the management of severely extruded immature maxillary incisors and the outcome of revascularization to treat subsequent pulp necrosis. An 8.5-year-old boy with severe dentoalveolar trauma to the anterior maxillary region as a result of a fall was provided emergency treatment consisting of reduction of the dislodged labial cortical bone and repositioning of the central incisors, which had suffered extrusive luxation. When he presented with spontaneous pain involving the traumatized incisors a week later, the teeth were treated via a revascularization protocol using sodium hypochlorite irrigation followed by 3 weeks of intracanal calcium hydroxide, then a coronal seal of mineral trioxide aggregate and resin composite. Complete periradicular healing was observed after 3 months, followed by progressive thickening of the root walls and apical closure. Follow-up observations confirmed the efficacy of the regenerative treatment as a viable alternative to conventional apexification in endodontically involved, traumatized immature teeth.     

Influence of splints and temporary crowns upon electric and thermal pulp-testing procedures.

The influence of different splints and temporary crowns upon the reliability of electric and thermal pulp-testing procedures was examined in 10 patients with vital maxillary central incisors and 10 patients with vital maxillary central incisors and 10 patients with unilateral pulp necrosis of a central incisor. The pulp-testing procedures were: (1) Bofors Pulp Tester, (2) Siemens Sirotest, (3) heated guttapercha, (4) ice, and (5) carbon dioxide snow (Odontotest). The splints or temporary crowns were: (1) silver cap splint, (2) acrylic cap splint, (3) Hawley orthodontic plate, (4) Saur's arch bar, (5) orthodontic bands, (6) stainless steel crown, and (7) stainless steel crown with labial surface removed. A reliable electrometric pulp response could only be elicited if the pulp tester was applied directly upon enamel and preferably upon the incisal edge. In this instance metal splints or partial steel crowns applied to the tooth had no effect on the pain threshold. A false positive reaction in case of pulp necrosis was only elicited when the electrode was placed directly upon metal which contacted neighboring vital teeth. The use of ice and heated guttapercha appeared to be of limited value, due to inconsistent pulp responses. Carbon dioxide snow gave a reliable response, unless applied on the incisal edge.     

Management of subluxation injury in a thumb-sucking child: a case report

Abstract –  This case report presents use of a custom trauma splint that was fabricated to prevent excessive thumb-sucking trauma to a previously-subluxated permanent incisor. A 10-year-old boy was referred to the clinic 10 days after falling in the schoolyard that resulted in a trauma to his maxillary left central incisor. The extent of clinical mobility stipulated fabrication of a custom trauma splint that would prevent further trauma to the incisor caused by excessive pressure of the thumb. A light-cured resin composite splint, covering the incisal edges of the central incisors and labial surfaces of the lateral incisors was made, and approximately 1-mm composite within the impressions of central incisors were trimmed off. The splint was bonded to the neighboring lateral incisors with flowable resin composite and root canal therapy was initiated on the subluxated incisor. After one week, the patient stopped his sucking habit completely. The treatment not only allowed for complete healing of the subluxated incisor without being exposed to further trauma, but also for spontaneous eruption of the tooth and closure of the existing open-bite.     

Intraradicular splinting of a horizontally fractured central incisor: a case report

Abstract – This case report presents the endodontic management of a horizontally fractured right incisor involving healing with granulation tissue using an intraradicular splinting technique. We also discuss the spontaneous healing of the fractured left central incisor with calcified tissue. A composite resin splint was made for all of the upper anterior teeth. The root canal of the right incisor was temporarily filled with calcium hydroxide slurry. The intraradicular splinting involved placing a file in the canal. Sealer was introduced into the canal and then a no. 110 K file was fixed in the canal with polycarboxylate cement. The tooth was asymptomatic and the composite splint was removed after 1 month. The right incisor appeared normal clinically and radiographically at the 30‐month recall. This case demonstrates that intraradicular splinting can be used to manage horizontally fractured teeth with necrotic and mobile coronal segment.     

Intrusive luxation: a case report

Abstract –  Intrusive luxation is one of the most severe types of dental trauma. The occurrence of pulp necrosis in intruded teeth with open apices is 100%. The risk of development of inflammatory or replacement root resorptions is high. Thus, endodontic intervention is required soon after the occurrence of trauma, in an attempt to prevent or delay the appearance of such lesions. On the other hand, the access to the root canal is difficult, as the crown is intruded. A multidisciplinary approach comprising Surgery, Orthodontics and Endodontics is required to allow exposure of the crown, orthodontic extrusion and onset of endodontic therapy. The patient GCSA, aged 15 years, attended the community project 'Lugar de dente é na boca' ('teeth should be in the mouth') of the Federal University of Goiás, Brazil, 1 week after complete intrusion of the right maxillary central incisor. Radiographic examination revealed that the incisal edge of this tooth was at the level of the crown-root interface of the adjacent teeth. After surgical exposure of the crown, pulp sensitivity was evaluated and was found to be negative. After onset of endodontic therapy, the patient was referred for orthodontic extrusion of the intruded tooth. Successive changes of root canal dressing were performed and the root canal was definitely obturated at 3 years and 6 months after onset of treatment. The present paper reports on a case of severe intrusive luxation, discusses the different treatments recommended for repositioning of traumatically intruded teeth, and questions the ideal period of maintenance of calcium hydroxide dressing in the root canal, in an attempt to prevent the occurrence of root resorption and repair any existing resorption.     

Management of a Class I malocclusion with traumatically avulsed maxillary central and lateral incisors

This case report describes orthodontic space closure for managing an avulsed maxillary central incisor and a lateral incisor in a growing girl with a Class I deep bite malocclusion with moderate lower and mild upper crowding. The treatment approach moved a central incisor across the midline and substituted a lateral incisor for a central incisor, in combination with canine substitution. Veneers on all maxillary anterior teeth attained acceptable esthetics. The right central incisor was moved to serve as the avulsed left central incisor. The right lateral incisor was moved to the position of the right central incisor and restored. The canines on both sides were substituted as lateral incisors; the posterior occlusion was left in Class II. Mesialization of central and lateral incisors with prosthetic rehabilitation is an acceptable treatment option.     

Developmental dental alterations in permanent teeth after intrusion of the predecessors: clinical and microscopic evaluation

Abstract – This case report describes the management of developmental dental alterations in permanent dentition as a consequence of severe intrusive luxation in its predecessors in a child of 2 years. At 10 years of age, this patient was referred for consultation due to lack of permanent maxillary right central and lateral incisors. Radiographic examination revealed impaction of hypoplasic permanent maxillary central incisor, absence of the lateral incisor and compound odontoma in region of the permanent maxillary lateral incisor. The odontoma was surgically removed and unerupted central incisor was placed in orthodontic traction over a period of 8 months. The central incisor presented with abnormal shape and was restored with composite resin. Odontoma histologic analysis was carried out through Hematoxylin and Eosin coloration and Scanning Electron Microscopy. Cement and osteocement formations were found in soft tissue, as well as some irregularly distributed dentine islands of tooth‐like structures, indicative of compound odontoma. We followed up this patient for 5 years and orthodontic management was successfully performed for correct alignment of the maxillary right central incisor impacted by compound odontoma.     

Longitudinal clinical and radiographic evaluation of severely intruded permanent incisors in a pediatric population

Abstract – Intrusion is defined as the axial dislodgment of the tooth into its socket and is considered one of the most severe types of dental trauma. This longitudinal outcome study was undertaken to evaluate clinically and radiographically severely intruded permanent incisors in a population of children and adolescents. All cases were treated between September 2003 and February 2008 in a dental trauma service. Clinical and radiographic data were collected from 12 patients (eight males and four females) that represented 15 permanent maxillary incisors. Mean age at the time of injury was 8 years and 9 months (range 7–14 years and 8 months). Mean time elapsed to follow‐up was 26.6 months (range 10–51 months). The analysis of data showed that tooth intrusion was twice as frequent in males. The maxillary central incisors were the most commonly intruded teeth (93.3%), and falling at home was the main etiologic factor (60%). More than half of the cases (53.3%) were multiple intrusions, 73.3% of the intruded teeth had incomplete root formation and 66.6% of the teeth suffered other injuries concomitant to intrusion. Immediate surgical repositioning was the treatment of choice in 66.7% of the cases, while watchful waiting for the tooth to return to its pre‐injury position was adopted in 33.3% of the cases. The teeth that suffered additional injuries to the intrusive luxation presented a fivefold increased relative risk of developing pulp necrosis. The immature teeth had six times more chances of presenting pulp canal obliteration that the mature teeth and a lower risk of developing root resorption. The most frequent post‐injury complications were pulp necrosis (73.3%), marginal bone loss (60%), inflammatory root resorption (40%), pulp canal obliteration (26.7%) and replacement root resorption (20%). From the results of this study, it was not possible to determine whether the type immediate treatment had any influence on the appearance of sequelae like pulp necrosis and root resorption after intrusive luxation, but the existence of additional injuries and the stage of root development influenced the clinical case outcome in a negative and positive manner, respectively.     

A case of incidental identification of mesiodens in 1-year-old boy followed for 6 years

We present a case of mesiodens identified in a 1-year 9-month-old boy. The patient visited our clinic after receiving a traumatic injury, which caused intrusion of the maxillary right and left primary central incisors. A periapical radiograph revealed no root fractures, though a mesiodens was incidentally found. The intruded teeth naturally moved into their original positions and periodical examinations were scheduled. At 4Y2M, uncommon mesial inclination of the maxillary right primary central incisor was noted. A radiographic examination showed the enlarged dental follicle of the mesiodens, which appeared to cause the inclination, and we planned fenestration when enlargement of the lesion was identified. At 5Y1M, he received another traumatic injury and the maxillary right primary central incisor was exfoliated. At 5Y5M, the mesiodens spontaneously emerged into the oral cavity and a radiographic examination showed prominent rotation of the maxillary right central incisor. Two-thirds of the crown of the mesiodens could be seen at 6Y4M. At 6Y11M, the patient again received a traumatic injury, and intrusion of the maxillary left primary central incisor was observed. At 7Y0M, the mesiodens and maxillary left primary central incisor were extracted under infiltration anesthesia, after which inclination of the axis of the adjacent maxillary right central incisor gradually improved.