Reposition of intruded permanent incisor by a combination of surgical and orthodontic approach: a case report

This report presents a case of a completely intrusive luxation of an immature permanent central incisor in a 7 years 9 months-old girl. Because there are severe intrusive trauma and cortical alveolar bone fracture, it was impossible to reposition with orthodontic or surgical method alone. The intruded tooth was repositioned to healthy alveolar bone level by using surgical extrusion and stabilization with sutures and periodontal pack. After healing of adjacent bone, the intruded maxillary central incisor erupted orthodontically by removable orthodontic appliance. It was moved from a high position to level of adjacent tooth in about 7 months. A radiograph was taken 6 months after ceasing forced eruption, which demonstrated minor root resorption, but the alveolar bone height had increased.     

Intrusive luxation of 60 permanent incisors: a retrospective study of treatment and outcome

Abstract – Background/Aim: Intrusive luxation in the permanent dentition is an uncommon injury but it is considered one of the most severe types of dental trauma because of the risk for damage to the periodontal ligament, pulp and alveolar bone. Management of intrusive luxation in the permanent dentition is controversial. The purpose of this study was to evaluate pulp survival and periodontal healing in intrusive luxated permanent teeth in relation to treatment alternatives, degree of intrusion and root development. Material and Method: The material consisted of 60 intruded permanent teeth in 48 patients (32 boys and 16 girls) aged 6–16 years (mean 9.4, median 9.0). The observation time was 6–130 months (mean 47.8, median 40.0). The analysed treatments were spontaneous re‐eruption (17 teeth), orthodontic extrusion (12 teeth) and surgical reposition (31 teeth). The degree of intrusion was registered as mild (0–3 mm), moderate (4–6 mm) and severe (≥7 mm). Root development was categorized with respect to root formation and development of the apex into four stages; one‐quarter to three‐quarters root formation, full root formation with open apex, full root formation with half‐closed apex and full root formation with apex closed. Ankylosis‐related resorption with pulp necrosis was diagnosed in 20 teeth, ingrowth of bone apically in two teeth, pulp necrosis without ankylosis‐related resorption in 23 teeth and pulp revitalization occurred in 15 teeth. Results: Significant correlations to the treatment outcome were root development (P = 0.03) and degree of intrusion (P = 0.03). Conclusions: No firm conclusion could be drawn for the difference in outcome between orthodontic extrusion and surgical reposition. To conclude, evaluation of the prognosis for intruded teeth should be based on the stage of root development and degree of intrusion. In teeth with immature root development, no active treatment appears to result in fewer healing complications.     

Spontaneous re-eruption of intruded permanent incisors: five case reports

This report presents 5 cases of intrusive luxation in immature permanent central incisors. The intruded incisors, with careful monitoring, were allowed to spontaneously re-erupt, which avoided the need to reposition the tooth either orthodontically or surgically. All of the teeth re-erupted spontaneously in a few months. The root development continued in all of the cases and all pulps remained vital. There were no other signs of pulpal and/or periapical pathology. It can be concluded that intruded immature permanent teeth can spontaneously re-erupt, conserve their vitality, and continue their root development without any surgical or orthodontic management.     

年轻恒牙嵌入性脱位的X线追踪观察分析

目的:通过对年轻恒牙嵌入性脱位的X线片进行回顾性研究,观察患牙复位、牙根发育和牙根吸收情况,并分析其影响因素。方法:收集2013年1月~2019年3月发生嵌入性脱位的年轻恒牙病例,分析其X线片,了解患牙复位、牙根发育及牙根吸收情况。结果:所有患牙基本复位,牙根继续发育占66.7%,发生替代性吸收占25%;嵌入程度较轻的患牙利于牙髓存活(P=0.008);自然再萌的患牙可减少替代性吸收(P=0.005);牙髓存活的患牙牙根可发育,且无替代性吸收(P<0.001)。结论:嵌入性脱位的年轻恒牙牙髓可存活,且牙根可继续发育。牙髓存活的患牙利于牙根发育、减少替代性吸收。重度嵌入的年轻恒牙可有萌出潜力。     

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.     

Surgical repositioning of a traumatically intruded permanent incisor in a patient with rheumatic fever: case report

Abstract –  Intrusive luxation of permanent teeth is a relatively uncommon type of injury to the periodontal ligament. However, it is one of the most severe types of dentoalveolar trauma. By definition, intrusive luxation consists of the axial displacement of the tooth into the alveolar bone, accompanied by comminution or fracture of the alveolar bone. Here we report the treatment management of a traumatically intruded immature permanent central incisor by surgical repositioning undertaken in a 10-year-old child with rheumatic fever 10 days after sustaining a severe dentoalveolar trauma. The intraoral examination showed the complete intrusion of the permanent maxillary right central incisor and the radiographic examination revealed incomplete root formation. Prophylactic antibiotic therapy was prescribed and the intruded tooth was surgically repositioned and endodontically treated thereafter. The postoperative course was uneventful, with both clinically and radiographically sound conditions of the repositioned tooth up to 3 years and 2 months of follow-up. These outcomes suggest that surgical repositioning combined with proper antibiotic prophylaxis and adequate root canal therapy may be an effective treatment option in cases of severe intrusive luxations of permanent teeth with systemic involvement.     

Immediate vs late orthodontic extrusion of traumatically intruded teeth

Abstract –  Although the published papers about this matter is limited to clinical case reports, the aim of this review was to quantify the success rate of immediate vs late orthodontic extrusion of traumatically intruded teeth. From 55 reports in a PubMed and Medline computerized search, 13 reported patients involving 22 traumatically intruded anterior upper teeth with orthodontic extrusion were selected. In the sample of 13 patients, six were males and seven females and the average age was 16.4 years old. The selection criteria were patients presenting traumatized anterior upper teeth resulting in intrusive luxation, with at least 1 year follow-up period. Orthodontic extrusive forces were applied in the immediate group within 10 weeks post-trauma, while in the late group the forces were applied only after 3 months post-trauma. Immediate and late orthodontic extrusion was extremely favorable. The success rate (without or with complications) was 95.4% against only 4.5% (1 tooth) because of inflammatory root resorption with rapid progression. All mature teeth (100%) were endodontically treated. Among the 12 immature traumatically intruded teeth, eight were endodontically treated and four were not. A high rate of success was reported in the literature in traumatically intruded teeth orthodontically extruded, either immediate or late.     

Management of bilateral impacted upper canines by single tooth dento-osseous osteotomy

When it is difficult to treat impacted teeth with orthodontic traction, surgical techniques including intentional luxation, autografts and distraction osteogenesis may be performed. However, these techniques are associated with problems such as root resorption, gingival recession and pulp circulatory disorders after extrusion. Single tooth dento-osseous osteotomy is considered to be a surgical technique with minimal effect on the pulp and periodontium. We used this method to treat a patient with impacted permanent canine teeth. After concomitant single tooth dento-osseous osteotomy and orthodontic treatment, root resorption of the bilateral canines was kept to a minimum and pulp vitality was confirmed. This method may be effective in patients in whom ordinary traction is difficult.     

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.     

The effect of orthodontic extrusion on traumatically intruded teeth

The management of traumatically intruded permanent incisors is controversial. Some authors suggest a decreased incidence of ankylosis in cases treated with orthodontic extrusion. The purpose of this study was to examine two common management techniques for traumatic intrusion, orthodontic extrusion, and observation for re-eruption. The four first premolars of three shepherd dogs were traumatically intruded with a mallet while a holding device was used to prevent tooth fracture. Five to 7 days following the injury, orthodontic force was applied unilaterally while the contralateral tooth served as the untreated control. To facilitate serial periapical radiography, x-ray jigs were fabricated for each animal and tantalum implants were placed in the bone distal to the permanent canine and first and second premolars. Observations included radiographic measurement of tooth movement, clinical estimates of tooth mobility, and radiographic and histologic assessment of root resorption, ankylosis, and periapical pathosis. The amount of traumatic intrusion varied from less than 0.5 to 4.1 mm. Following 11 to 13 weeks of force activation, 10 of 12 traumatized teeth showed clinical, radiographic, and histologic evidence of ankylosis irrespective of orthodontic treatment. Whereas the ankylosed teeth did not move with orthodontic forces, the teeth used for force application were orthodontically intruded 1.7 to 6.5 mm. When the injury to the tooth was severe, orthodontic extrusion had little effect on repositioning of the injured tooth but resulted in undesirable movement of the anchorage teeth. When the injury was less severe, orthodontic forces facilitated repositioning of the affected tooth.     

微创牵引复位外伤挫入年轻恒牙的临床疗效观察

目的研究微创正畸牵引复位无自发萌出能力的外伤挫入年轻恒牙的临床疗效。 方法选择年轻恒牙外伤挫入的患者8例,年龄7~ 11岁,共11颗上颌切牙,其中9颗重度挫入、2颗中度挫入。观察1个月以上,确定无自发萌出能力后,采用如下微创正畸牵引方式复位：（1）"2 × 4"镍钛弓丝技术：单颗牙中度挫入,邻牙萌出3/4以上;（2）活动基托牵引：重度根向挫入、邻牙萌出不足1/2或伴脱位性损伤;（3）活动基托牵引联合"2 × 4"镍钛弓丝技术：重度唇向或腭向挫入,邻牙萌出不足1/2或伴脱位性损伤。观察治疗后患牙萌出状况、牙根吸收、边缘骨缺损和（或）牙髓变化情况。 结果（1）患牙萌出状况：所有挫入牙均复位;（2）牙根吸收情况：4颗牙出现轻微根吸收,2颗牙牵引前出现根尖部和根中段侧方低密度影,治疗完成时低密度影消退,余牙均无牙根吸收;（3）边缘骨缺损情况：除2颗牙外均无边缘骨缺损;（4）牙髓活力状况：3颗牙齿发育Nolla 10期的挫入牙,牵引前即行牙髓摘除术,4颗牵引中行牙髓摘除术,4颗牙髓活力正常,其中1颗根管钙化。 结论无萌出潜力的挫入年轻恒牙可根据其挫入方向及邻牙萌出程度和受伤情况,分别选择"2 × 4"镍钛弓丝技术、活动基托牵引技术或活动基托联合"2 × 4"镍钛弓丝牵引技术,及时进行微创牵引,可有效复位挫入牙,避免牙根吸收,减少边缘骨缺损,并可能保存活髓,值得进一步推广。     

Long-term Complications of Previously Successful Regenerative Endodontic Procedures after Orthodontic Movement: A Report of 3 Different Complications after 4, 8, and 11 Years

There is a paucity of literature on late complications of regenerative endodontic procedures. The aim of this article was to report 3 cases of previously successful regenerative endodontic procedures with long-term follow-up that developed different complications after the application of orthodontic forces. In the first case, an 8-year-old female patient received a regenerative endodontic procedure in her previously intruded tooth (tooth no. 21) that had been rendered necrotic after a successful spontaneous repositioning procedure. The 5-year follow-up revealed uneventful healing, continuous root development, dentinal wall thickening, and regaining of pulp vitality for tooth no. 21. Four years later, the patient received orthodontic treatment with mild forces that lasted 2 years. The 11-year follow-up revealed severe external invasive cervical resorption, and the tooth had to be extracted. In the second case, a 6-year-old female patient suffered a lateral luxation injury in tooth no. 11. Six months after the injury, the tooth developed symptoms and discoloration and tested negative in pulp vitality testing. Single-step regenerative endodontic procedures were applied, and successful continuous root development, dentinal wall thickening, and apical closure were achieved at the 3-year follow-up. Two months after the initiation of orthodontic treatment, the tooth developed symptomatic apical periodontitis. Root canal treatment was performed to treat the disease, and the orthodontic treatment was continued. In the third case, a previously published successful regenerative endodontic procedure developed a perforating internal resorption 6 months after the application of orthodontic forces. The internal resorption was arrested with root canal treatment, the resorptive defect was repaired with bioceramic obturation, and the orthodontic treatment plan was modified. Previously successful regenerative cases might develop external invasive cervical resorption, regenerative tissue necrosis, or internal resorption after the application of orthodontic forces. Best practice/evidence-based guidelines on the appropriate orthodontic management of successful regenerative endodontic therapy teeth are lacking. Whenever possible, careful monitoring and partial or complete exclusion off orthodontic treatment might be necessary. In some cases, preventive root canal treatment before the initiation of orthodontic movement might be considered.     

年轻恒牙挫入性损伤的处理策略

年轻恒牙挫入性损伤是预后最差的牙外伤类型之一,常导致牙齿缺失,影响患儿的美观及健康.治疗方案通常包括观察再萌出、正畸牵引复位和外科复位3种;临床上应根据患牙的牙根发育情况及挫入程度,参考患儿及家长意愿,选择单独或结合使用上述3种治疗方案进行治疗.治疗后的主要并发症包括牙髓坏死、牙根吸收、牙槽骨边缘性吸收、根管闭塞等.尽...     

Conservative management of an intruded immature maxillary permanent central incisor with healing complication of pulp bone

Traumatic intrusion injury of permanent teeth is serious with multiple complications possible associated with the pulp, periodontal ligament, alveolar bone and Hertwig's epithelial root sheath. The optimal treatment for the management of an intrusion injury has not yet been determined. A case is presented involving the conservative management of an immature maxillary permanent central incisor intrusively luxated by allowing for re-eruption and orthodontic extrusion two weeks later. After a follow-up period of ten months, the intruded tooth continued to show a mobility of grade one, without metallic percussion tone or infra-occlusion, which confirmed periodontal ligament healing. Although the intruded tooth failed to respond to dry ice testing, no other signs of pulp necrosis were evident and the colour of the intruded tooth was within normal limits throughout the follow-up period. However, complications of healing of Hertwig's epithelial root sheath occurred, causing in-growth of bone and periodontal ligament into the root canal.     

Decoronation: indications and treatment timing

Dental trauma in children is a frequent event and may involve functional, esthetic and orthodontic complications. Replacement resorption and ankylosis are frequently diagnosed following avulsion and replantation, severe intrusive luxation, and less frequently as a consequence of lateral luxations and root fractures. The optimal treatment for an ankylotic permanent incisor is yet to be found. The treatment of ankylosis and replacement resorption of a permanent incisor following dental trauma is further complicated when it involves a growing child. It is often associated with increasing infraposition of the tooth, retarded growth of the alveolar bone and tilting of adjacent teeth. To avoid such complications an ankylosed tooth should be removed before they changes become so pronounced that they necessitate orthodontic intervention and compromise future prosthetic treatment. The purpose of this article is to review the literature dealing with the considerations involved in the treatment of a permanent incisor diagnosed with replacement resorption and ankylosis. Different treatment options are considered. Decoronation is described and discussed.     

Management of intrusive luxation injuries

Abstract Traumatic intrusion of permanent teeth is a relatively infrequent but serious type of dental injury, cine to the complicated picture it involves. Various treatment approaches have been suggested, so far, regarding management of intrusive luxation. Techniques aiming to reposition the intruded tooth include observation for spontaneous reeruption, surgical as well as orthodontic repositioning. However, development of complications such as pulp necrosis, inflammatory root resorption, replacement resolution and ankylosis and loss of marginal bone support makes selection of the most favorable technique controversial. In this paper, a critical review of the existing treatment modalities is attempted and treatment approaches based on diagnostic parameters that are indicative of the severity of an intrusive injury are presented. Recommendations are made after taking into consideration experimental and clinical study findings and observations from other author's and our own clinical experience. Two cases of intrusive luxation in children are presented and management of the dental injuries as well as the complications which occured are being discussed.     

Intrusive luxation of permanent incisors in Norwegians aged 6–17 years: a retrospective study of treatment and outcome

Abstract – Background/Aim: External replacement resorption (ankylosis‐related) is a severe complication leading eventually to tooth loss. Little information exists regarding the influence of variables such as degree of intrusion or treatment method on the development of replacement resolution in intruded permanent incisors. The aim of this study was to report the most frequently involved age group, the preferred type of treatment, and the type and frequency of healing complications. Special attention was paid to the effect of treatment on the occurrence of replacement resorption. Material and Methods: Fifty‐one intruded permanent incisors were studied in 20 boys and 19 girls aged 6 to 17 years. Only three patients were over 12 years of age. Complete intrusion had occurred in 21 teeth, and 31 teeth were classified as immature. Re‐eruption was awaited for 37 teeth. The remaining teeth were repositioned orthodontically (7 teeth) or surgically (7 teeth). Results: Re‐eruption occurred in 35 out of 37 teeth over a period of 3–12 months. After a mean observation period of 4 years ranging from 1–12 years, retained pulp vitality was recorded in 22 teeth (43%). Pulp necrosis had developed in 57%, inflammatory resorption in 26% and replacement resorption in 12%. Whereas all inflammatory resorptions were arrested after long‐term calcium hydroxide treatment, replacement resorption always led to complete root resorption. In the analysis all orthodontic and surgical repositioned teeth were combined into an active treatment group. The non‐active treatment group consisted of teeth allowed to re‐erupt. The distribution of replacement resorption was significantly lower in teeth allowed to re‐erupt than in teeth repositioned actively. Conclusions: The best treatment of intruded incisors in 6–12 year‐old children is to await re‐eruption. Should endodontic treatment be required before re‐eruption has occurred, a gingivectomy can be performed to gain access to the root canal.     

Emerging therapies for the management of traumatized immature permanent incisors

Early loss of immature permanent teeth due to pulpal necrosis secondary to trauma can have dire consequences for a child's growth and development. The treatment alternatives include surgical endodontics, traditional calcium hydroxide apexification, and mineral trioxide aggregate (MTA) apexification. These options pose potential complications, including: arrest of root development; weakened dentinal walls; and increased potential for fracture. Revascularization of the dentin-pulp complex is a new approach that involves disinfecting the root canal system followed by tissue repair and regeneration while allowing for continued root development and thickening of the lateral dentinal walls through deposition of new hard tissue. The purpose of this report was to present the revascularization of an immature permanent maxillary central incisor that had evidence of external root resorption. Six months later, internal bleaching was performed to remove cervical discoloration from the triple antibiotic paste. At 18 months, the tooth remained vital and had evidence of continued root development.     

Re-eruption of an intruded immature permanent incisor with necrotic pulp: a case report

Intrusive luxation is a serious dental injury that causes damage to the pulp and supporting structures of a tooth because of its dislocation into the alveolar process. This paper presents the case of the re-eruption of a severely intruded immature permanent incisor with a crown-root fracture. A 9-year-old boy was referred to the clinic 1 day after a fall. Clinical and radiographic examinations revealed intrusive luxation of the immature left permanent incisor and a crown-root fracture without pulp exposure. Palatal gingivectomy was done 2 weeks later to facilitate re-eruption. Root canal therapy with intracanal calcium hydroxide paste was initiated during the first month owing to severe spontaneous pain. Six months later, the tooth re-erupted to a normal position, after which root canal obturation and a final esthetic restoration were done. The present case demonstrates the possibility of obtaining re-eruption of intruded immature permanent teeth with interim medication (calcium hydroxide) in the root canal.     

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.