Orthodontic movement in traumatically intruded teeth: a case report

Abstract  – Intrusive luxation of permanent mature teeth is one of the most serious injuries to the periodontal ligament in dental traumatology. Various treatment approaches are currently practised. The treatment of choice for traumatically intruded teeth was to combine orthodontic repositioning and endodontic treatment. This case report describes the treatment of a 50-year-old male patient, with four completely intruded mature permanent maxillary incisors. Orthodontic extrusion was initiated 1 week after the trauma. After 10 days, the crowns of the teeth were exposed to start endodontic therapy. Nine weeks after the injury and 8 weeks after the beginning of orthodontic extrusion, the intruded incisors were back about to their original position before the displacement occurred. All treatment management as well as a follow-up 8 years after the trauma are described.     

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.     

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.     

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。     

Multidisciplinary treatment for a patient with traumatically intruded permanent canine and premolar

When selecting treatment for traumatically intruded teeth, various factors should be evaluated including the degree of intrusion, pulp vitality, patient's age and maturity of the tooth. Treatment options consist of surgical repositioning, orthodontic extrusion and spontaneous re‐eruption. This study describes a case of a 22‐year‐old male with traumatically intruded maxillary canine and first premolar that was treated comprehensively by an orthodontist, endodontist and prosthodontist two months after injury.     

Treatment of intruded permanent incisors: a multidisciplinary approach

Abstract The case presented is a report of a healthy 11- year-old boy, who fell down and traumatized his four maxillary incisors. Both central incisors were deeply intruded with concomitant uncomplicated crown fractures, and both lateral incisors suffered concussion. The intruded teeth were repositioned using a removable orthodontic appliance and were endodontically treated 3 weeks after trauma. Tooth 11 became ankylosed 3 months post trauma, and tooth 21 was extruded to its original position after 5 months. Five months post-trauma, teeth 12 and 22 underwent necrosis and were endodontically treated. In addition, tooth 22 presented an external inflammatory root re-sorption that was arrested by calcium hydroxide paste after 3 months. A crown-lengthening procedure was performed on tooth 11 10 months post-trauma, exposing the clinical crown to a better condition for restoration. All 4 incisors were restored with a composite material, and the incisal edges of the central incisors were shaped at the same level. Two months after the crown lengthening procedure, spontaneous eruption occurred on tooth 11, that had been ankylosed. The restored incisal edge of tooth 11 was reduced to the same level of tooth 21. The patient is under periodical examination till a definitive orthodontic treatment can be performed.     

Emergency orthodontic treatment after the traumatic intrusive luxation of maxillary incisors.

Treatment of traumatically intruded teeth is based largely on empirical clinical experience rather than on scientific data. The aim of this qualitative meta-analysis was to provide an evidence base to evaluate the orthodontic repositioning approach. In a MEDLINE search of the literature in English, 14 reported patients involving 22 teeth were found to have been treated by this modality. Additionally, 3 new patients, involving 9 intruded teeth and presented herein, were combined to form a total study sample of 17 subjects (7 girls, 10 boys, aged 8.9 +/- 1.2 years). Orthodontic extrusive forces were applied in the immediate posttrauma period (up to 3 months), with a variety of orthodontic appliances. Repositioning was achieved for 90.3% of the affected teeth but failed in 9.7% because of inflammatory resorption (2 teeth) or a misdiagnosis of root fracture (1 tooth). Early complications included loss of pulp vitality and external root resorption. All intruded teeth with closed root apices lost their vitality regardless of the degree of intrusion, whereas among those with incomplete apices, 45.5% that had been moderately intruded remained vital. External resorption was encountered in 54.8% of the teeth. Loss of marginal bone support was rarely encountered. Late complications included inflammatory root resorption in teeth with closed apices, in which endodontic treatment was not initially performed, and obliteration of the pulp tissue in teeth that remained vital. The results show that this method is superior to other treatment alternatives.     

正畸牵引复位法治疗外伤性上前牙嵌入的疗效观察

目的 观察正畸牵引复位联合固定术治疗外伤性上前牙嵌入的效果。方法 用正畸牵引复位联合树脂夹板固定，治疗外伤性上前牙嵌入病例24例、27颗牙，观察2a后的疗效。结果 27颗嵌入牙，牙根尚未形成者16颗。牙根形成者ll颗，治疗后11颗达到成功标准，16颗达有效标准，无失败病例。结论 正畸牵引复位联合树脂夹板固定是一种积极的、温和的治疗外伤性上前牙嵌入的方法，其疗效较理想。     

Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1

This is the first of two papers discussing the implications of dental trauma for patients requiring orthodontic treatment. This paper will focus on the factors the orthodontic specialist should consider when contemplating movement of traumatized teeth. The prevalence of dental trauma and the recognition and prevention of traumatic injuries are discussed. The evidence available in the literature relating to orthodontic tooth movement in vital and endodontically treated traumatized teeth is explored. The interdisciplinary management of root fractured and intruded teeth receive special attention. The second paper will look at the role of the specialist team in the management of failing anterior teeth and will outline possible treatment options for children and adolescents encountering such situations. Avulsion injuries and tooth transplantation are considered in particular detail.     

Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1

Abstract

This is the first of two papers discussing the implications of dental trauma for patients requiring orthodontic treatment. This paper will focus on the factors the orthodontic specialist should consider when contemplating movement of traumatized teeth. The prevalence of dental trauma and the recognition and prevention of traumatic injuries are discussed. The evidence available in the literature relating to orthodontic tooth movement in vital and endodontically treated traumatized teeth is explored. The interdisciplinary management of root fractured and intruded teeth receive special attention. The second paper will look at the role of the specialist team in the management of failing anterior teeth and will outline possible treatment options for children and adolescents encountering such situations. Avulsion injuries and tooth transplantation are considered in particular detail.     

Treatment selection for anterior endodontically involved teeth.

Innovations in material science and clinical techniques have expanded the number of treatment options available for nonvital anterior teeth. These options include the use of composite to fill the access opening with no additional treatment, crown placement, orthodontic extrusion, crown lengthening with or without orthodontic extrusion, dowel restorations with crown placement, and fixed bridge or implant therapy when extraction is necessary. Clinicians need to understand the benefits and limitations of each option in order to provide their patients with optimum function and aesthetics. Using case presentations, this article describes predictable approaches for the diagnosis, treatment planning, and restoration or replacement of endodontically treated teeth in the anterior region.     

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.     

Restoration of traumatized anterior teeth by interdisciplinary approach: report of three cases

These cases had been discussed having massive coronal fracture, rotation and intrusion of teeth. In case one, both the central incisors, i.e. 11 and 21 were fractured only one-third of tooth material was remaining. In case two, 21 was fractured and intruded. In case three, 12 and 21 were avulsed and 11 was rotated and intruded. These cases were successfully treated by multidisciplinary approach. Fractured crown with periapical pathology were endodontically treated and then rotated and intruded teeth were repositioned by removable or fixed orthodontic appliance. Subsequent to endodontic and orthodontic treatment prosthodontic rehabilitation was done.     

Traumatically intruded teeth

Various combinations of orthodontic force, luxation, and observation are applied to 12 teeth traumatically intruded in 3 large dogs. All showed root resorption to some degree. Early orthodontic repositioning, with luxation if immobile, produced the best recovery.     

使用改型腭杆辅助压低过长上后牙的临床研究

目的评价使用改型腭杆辅助压低过长上后牙的临床效果。方法5名成年患者,因无法使用种植体支抗而使用改型腭杆辅助压低5颗过长的上后牙。在矫治前、后采取研究模型,进行三维测量,明确过长后牙的压低量和支抗后牙的移动量。通过曲断体层片观察上后牙压低后其牙根吸收情况。结果5名患者均完成上后牙压低,平均疗程为6个月。模型测量表明：过长后牙的压低量为（2．29±0．44）mm。采用配对样本t检验表明过长牙的压低量有显著的统计学意义（P〈0．001）;支抗后牙有的伸长,有的被压低,移动量范围是-0．24mm～0．71mm（负值为伸长量,正值为压低量）,支抗牙的移动量没有显著的统计学意义（P〉0．05）。X片显示被压低的上后牙和支抗牙没有出现明显的牙根吸收。结论对于不适合植入支抗钉压低过长后牙的患者使用改型腭杆辅助压低是一种有效的正畸矫治方法。     

Clinical and histological alterations in the surrounding periodontium of dog's teeth submitted for an intrusive luxation

Abstract –  The clinical and histological alterations on periodontium of dog's teeth after an intrusion luxation was analyzed. An impact device was used on 12 teeth of six adult dogs with the purpose of making a dislocation on the long axis of these teeth. Of the teeth that suffer intrusion luxation, two did not receive treatment and ten were replaced by orthodontic extrusion with activated springs of 100 gf. The traction was initiated either immediately after the trauma or 7 days later. Observation time was 40 days. Endodontic therapy with calcium hydroxide was performed on the fourteenth day after the intrusive luxation. The intruded teeth that did not receive appropriate treatment had signs of extensive and progressive inflammatory resorption. The teeth that were moved immediately after the trauma had lesser degree of replacement resorption compared with those that were extruded 7 days after the trauma.     

根管治疗牙正畸加力后根吸收的相关因素研究

目的研究固定正畸治疗对根管治疗牙牙根吸收的影响和相关因素分析。方法选择正畸治疗前口腔内已完善根管治疗牙45例,利用治疗前后的全口曲面断层片,以改良根吸收分级法评估患者治疗前后牙根形态变化,分析正畸治疗对根管治疗后牙根吸收的影响。结果①正畸治疗后根管治疗牙牙根吸收有所增加,差异具有统计学意义（P〈0．001）;②性别是影响正畸治疗后根管治疗牙牙根吸收方程最为显著的因素（P〈0．05）,提示女性发生根吸收的风险大于男性;③正畸治疗后根管治疗牙与对侧活髓牙比较牙根吸收程度的改变差异没有统计学意义（P〉0．05）;④在所观察的样本中,无论根管治疗牙齿与活髓牙均未见3级根吸收。结论根管治疗牙在固定正畸治疗后可能发生一定程度的根吸收改变,但并不比活髓牙的风险更高。     

Root resorption after orthodontic intrusion and extrusion: an intraindividual study

The aim of this investigation was to compare root resorption in the same individual after application of continuous intrusive and extrusive forces. In nine patients (mean age 15.3 years), the maxillary first premolars were randomly intruded or extruded with a continuous force of 100 cN for eight weeks. Eleven maxillary first premolars from six randomly selected orthodontic patients served as controls. Root resorption was determined using scanning electron microscopy. Quantitative assessment of the percentage of resorbed area of the total root surface was performed on composite micrographs. The severity of root resorption was also assessed by visual scoring of the roots. Root resorption mainly occurred at the apical part of the roots in both experimental groups. A significant difference in root resorption was found between the intruded and the control teeth (P = .006) but not between the extruded and the control teeth. However, the mesial and distal root surfaces showed resorption on 5.78 +/- 3.86% of the root surface of the intruded teeth and 1.28 +/- 1.24% of the root surface of the extruded teeth, and this difference was significant (P = .004). In addition, a large individual variation was found. From this study, it can be concluded that intrusion of teeth causes about four times more root resorption than extrusion. Because the amount of root resorption due to intrusion or extrusion in the same patient is correlated, every clinician should be aware that the extrusion of teeth might also cause root resorption in susceptible patients.     

Forced orthodontic extrusion to restore extensively damaged anterior and premolar teeth as abutments for single-crown restorations: Up to 5-year results from a pilot clinical study

Statement of problemClinical data on orthodontic extrusion to restore teeth deemed unrestorable because of their defect size are scarce. It remains unclear for which defects forced orthodontic extrusion and tooth retention is preferred to extraction.PurposeThe purpose of this pilot clinical study was to investigate the survival, frequency, and type of complications of extensively damaged teeth requiring single-crown restorations after forced orthodontic extrusion.Material and methodsParticipants were recruited from consecutive patients in need of restorative treatment of extensively damaged teeth at a university clinic. The teeth were orthodontically extruded to reestablish the biologic width and to ensure a 2-mm ferrule preparation before restoration. The primary endpoint was restoration success and survival. At recall, survival was defined as the tooth being in situ and success as a symptom-free tooth with an intact, caries-free restoration and with physiological pocket probing depths, no signs of intrusion, ankylosis, root resorption, or periapical radiolucency. Recalls were performed every 6 months; the outcome was assessed by radiographic and clinical evaluation after up to 5 years of clinical service. Quantitative parameters were described with mean values and standard deviations.ResultsThirty-four participants were assessed for eligibility and enrolled (mean ±standard deviation age: 53.4 ±18.9 years). Four participants were premature dropouts. Data were analyzed for 35 teeth in 30 participants. The amount of extrusion varied between 2 and 6 mm (mean ±standard deviation 3.4 ±0.9 mm). The mean duration of extrusion was 18.9 ±12.6 days and the mean duration of retention was 126.94 ±88.1 days. The mean ±standard deviation crown-to-root ratio after treatment was 0.8 ±0.1 (range: 0.5 to 1.0). Three participants exhibited orthodontic relapse before restoration. Teeth were successfully restored after repeated extrusion. After a mean observation period of 3.3 years (range: 1 to 5.2 years), 29 of 31 teeth were still in situ. Two teeth were fractured, and 4 participants were not available for recall. Thus, the survival rate was 94%. No resorption or periapical translucencies were observed radiographically. Clinical examinations revealed physiological probing depths and absence of ankyloses. One tooth presented with marginal bone loss. The most frequent type of complication was orthodontic relapse at recall (n=3). A total of 84% of teeth were considered a success.ConclusionsForced orthodontic extrusion allowed for the restoration of anterior and premolar teeth deemed as nonrestorable because of their defect size. Tooth retention of extensively damaged teeth and their use as abutments for single-crown restorations can be recommended.     

Changes in Vertical Tooth Position and Face Height Related to Long Term Anterior Repositioning Splint Therapy

This study evaluates whether extended full-time wear of a partial coverage mandibular anterior repositioning splint (MORA) causes intrusion of posterior teeth and determines the effect on jaw position. Sixty-four patients from two private orthodontic practices were studied using cephalometric radiographs to measure vertical change in position of the anterior and posterior teeth and the mandible. The splint wear time ranged from a minimum of one half year to a maximum of 4.8 years, with a mean of 1.33 years. No significant change was recorded in the distance from the mandibular molar to the mandibular plane. On average, the maxillary incisor and maxillary molar extruded about 1 mm, while the mandibular molar was unchanged and the mandibular incisor intruded about 0.6 mm. Posterior face height increased an average of 1.6 mm, and anterior face height increased an average of 2.7 mms. In 20% of the patients, intrusion of the mandibular molars of 1 mm or more occurred. In 41%, extrusion of the maxillary incisors of 1 mm or more was noted. Intrusion of the upper molars or extrusion of the lower incisors occurred in only 5% of the patients. The data indicates that only a very small proportion of patients having long term splint therapy using the MORA have clinically significant molar intrusion. Change in mandibular position was expressed in a vertical increase in posterior and anterior face height. Only very small changes occurred in antero-posterior position.