Australian Dental Journal

Australian Dental Journal The official journal of the Australian Dental Association Australian Dental Journal 2014; 59: 240 244 doi: 10.1111/adj.12164 Management of traumatically intruded young permanent tooth with 40-month follow-up V Chacko,* M Pradhan *Department of Pedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal University, Mangalore, India. Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu, Nepal. ABSTRACT Background: Intrusive luxation injuries often result in severe damage to the tooth, periodontal ligament and pulpal tissue. Furthermore, treatment outcome is often unpredictable because of the large number of injury related variables which influence choice of treatment and prognosis. This report presents the case of a 9-year-old boy with a 6 mm intruded permanent maxillary central incisor with an open apex. Methods: The treatment option chosen was to wait and watch for spontaneous re-eruption. At the end of two weeks, the tooth showed signs of pulp necrosis and external root resorption. A palatal mucoperiostal flap was reflected and endodontic access was established, following which an intracanal medicament of calcium hydroxide was applied. By the end of the fifth month, there was radiographic evidence of apical barrier formation and by the tenth month, the tooth had re-erupted to the level of the adjacent central incisor. Root canal treatment was completed at the end of 24 months and the root was reinforced using a glass fibre post. Results: At the last follow-up visit (40 months after trauma), the tooth was asymptomatic and radiographic examination showed satisfactory periapical and periodontal healing. Conclusions: Spontaneous re-eruption is possible, even in severely intruded teeth with open apices. Keywords: Intrusion, open apex, trauma. Abbreviations and acronyms: IOPA = intraoral periapical. (Accepted for publication 16 June 2013.) INTRODUCTION Intrusive luxation is a rare type of dental injury in which the tooth is displaced further into the alveolar bone by a traumatic force. It comprises 0.3% to 1.9% of all traumatic injuries in the permanent dentition, 1,2 and peak incidence is in the 6 12 years age group. 2 Intrusive luxation is a severe type of trauma, resulting in injury to the tooth structure, periodontal ligament cells and fibres, pulp tissue and alveolar bone. When this type of injury occurs in children in teeth with open apices, there is also the possibility that tissue in the apical area will be severed and the socket bone penetrate the apical opening. 3 Intrusive luxations are one of the most difficult types of injury to treat as there are differing opinions on what constitutes the best treatment. 4,5 The two main variables determining choice of treatment are the stage of root development and the severity of the intrusion. 6 Treatment options available include passive repositioning, i.e. allowing the tooth to reerupt, and active repositioning, either surgically or by use of orthodontic appliances. 2 Treatment is further complicated by the fact that intrusive luxations are associated with a high risk of complications during healing, including pulpal necrosis, external inflammatory resorption, replacement resorption and marginal bone loss. 4 As intrusive luxations are most commonly seen in the pre-adolescent age group, proper management of the injury and its numerous complications is extremely important for the patient to complete optimum facial and occlusal development. Due to the rare occurrence of intrusive luxations, there is a scarcity of published data on the management and prognosis of this type of injury. 2 Therefore, as suggested by Tsilingaridis et al., 7 it is important to report cases of intrusive luxations to help form a consensus on treatment strategies and outcomes. This case aims to report the management and outcome at the end of 40 months of a severely intruded young permanent incisor in a 9-year-old patient. 240 2014 Australian Dental Association

Management of traumatically intruded incisor Fig. 2 Pre-op IOPA. Fig. 3 IOPA at 2 weeks. Fig. 1 Pre-op. CASE REPORT A 9-year-old boy reported to our department with a complaint of pain in the upper anterior region. The patient reported falling at home the same day. There were no episodes of loss of consciousness or discharge from nose or ears following the fall. However, the patient gave a history of bleeding from the oral cavity which ceased without any intervention. The patient had an abrasive injury to the chin, and the lower lip appeared slightly swollen and oedematous. Intraorally, an ulcer approximately 6 mm in diameter was present on the lower lip. The upper right central incisor appeared to be intruded, with only 1 mm of the incisal edge clinically visible (Fig. 1). An intraoral periapical (IOPA) radiograph of the intruded tooth was taken. It showed obliteration of the periodontal ligament space in relation to the intruded tooth and an open apex in relation to the adjacent left central incisor (Fig. 2). The root of the right central incisor appeared shortened, suggesting that the root was most likely displaced labially (Fig. 2). The tooth did not respond to electric pulp test or cold test. Depth of intrusion, measured from the incisal edge of the intruded tooth to the incisal edge of the adjacent central incisor, was 6 mm. As the adjacent tooth had an open apex, it was assumed that the intruded tooth would also be at a similar stage of development, which was confirmed by subsequent radiographs (Fig. 3). Hence it was decided to review the patient at regular intervals and wait for spontaneous re-eruption. The patient was prescribed antibiotics (amoxycillin, 500 mg, t.i.d) for 5 days, analgesic (Ibugesic Plus, Cipla, t.i.d) for 3 days and asked to rinse his mouth with 0.2% chlorhexidine mouthwash (Clohex 150, Dr Reddy s) and report after 5 days. At the subsequent appointment, he complained of mild intermittent pain and pus discharge from the gingival sulcus in relation to the intruded incisor. On examination, pus discharge was evident from the labial sulcus of the intruded tooth on palpation. However, the tooth was not tender on percussion and did not show any abnormal mobility. The depth of intrusion was 5.5 mm. The gingival sulcus was irrigated with povidone iodine and the patient was given a metronidazole containing ointment (Metrogyl, Metro Gel, Intra Labs) for topical application and asked to report after 1 week. When the patient returned, there was continued pus discharge from the 2014 Australian Dental Association 241

V Chacko and M Pradhan sulcus in relation to the intruded central incisor and the tooth showed Grade 1 mobility. An IOPA radiograph showed signs of external root resorption in relation to the intruded tooth (Fig. 3). Root canal access opening was done after reflection of a palatal mucoperiosteal flap (Fig. 4). The root canal was cleaned and disinfected using 5.25% sodium hypochlorite, saline and chlorhexidine, and subsequently filled with a calcium hydroxide-iodoform paste (Metapex; Meta Biomed Ltd, Cheongju, Chungbuk, Korea). The mucoperiosteal flap was then replaced and sutured. After 1 week, the tooth did not show any abnormal mobility or pus discharge from the sulcus and the degree of intrusion had reduced to 4.5 mm. The patient was advised to report for followup initially after 2 weeks (intrusion had reduced to 4.0 mm) and at 1-month intervals thereafter. The calcium hydroxide was changed at 3-month intervals. By the fifth month radiographic examination revealed the presence of a calcific barrier at the apex and the external root resorption appeared to have ceased. The tooth re-erupted to its normal level by the tenth month (Figs. 5 and 6). It was decided to continue with the calcium hydroxide intracanal medicament to ensure there was no progress in the resorption process. At the end of 24 months, the root canal was filled with gutta percha and sealer (AH Plus, Dentsply De Trey GmbH, Germany). The root canal was then prepared and restored with a glass fibre post (Mirafit 3 in 1, Hager Werken, Germany) which was cemented using a dual cure self-adhesive resin cement (Rely X U 100, 3M ESPE, Germany). This was done to reinforce the roots and reduce the chances of root fracture. 8 The patient was reviewed at 6-month intervals. The tooth continued to be asymptomatic with no abnormal mobility, normal response to percussion and normal probing depths. The last recall visit was 40 months after the patient s first visit. The tooth was Fig. 5 IOPA at 10 months. Fig. 6 At 10 months. asymptomatic and clinically functional with normal probing depths (Fig. 7). Radiographic examination confirmed the absence of active inflammatory external resorption or replacement resorption (Fig. 8). The patient was advised to report for review every 6 months. Fig. 4 Access opening after palatal flap reflection. DISCUSSION Intrusive luxation is a rare but severe type of dental trauma because it is often associated with crushing injury of the periodontal ligament and alveolar bone, and rupture of neurovascular supply to the pulp. 9 The healing and prognosis following intrusion depends on a number of pre-injury and injury factors. 3 An earlier degree of root development was considered to be important in determining prognosis. 10 However more recently, the severity of intrusion has been reported to be the most important factor for determining the prognosis. 11 Studies have suggested that intrusions up to 3.0 mm have an excellent prognosis, whereas intrusions greater than 6.0 mm have a poorer prognosis 242 2014 Australian Dental Association

Management of traumatically intruded incisor Fig. 7 At 40 months. Fig. 8 IOPA at 40 months. with greater chances of pulp necrosis and inflammatory root resorption. 4,12 In the case presented the depth of intrusion was 6.0 mm and the intruded tooth had an open apex, with root length completed. Treatment options for intruded teeth include waiting for spontaneous re-eruption or repositioning the tooth, either surgically or by orthodontic means. The advantages of repositioning include relief of compression zones in the periradicular area, enabling better healing by cemental deposition rather than ankylosis. 13 Repositioning also enables early endodontic access which can help prevent the onset of inflammatory root resorption. 11 However, repositioning might inflict further trauma to the already damaged periodontal tissue, leading to an increase in complications during the healing period. 13 We decided not to actively intervene but to wait and watch for re-eruption as many investigators have suggested that intruded immature teeth do re-erupt spontaneously. 10,14 This approach has also been recommended by the British Society of Pediatric Dentistry in their guidelines in 2010 1 and the International Association of Dental Traumatology in 2012. 15 One of the drawbacks of this approach is that root resorption might become quite advanced during the waiting period. 9 As the tooth is still intruded, endodontic intervention which is necessary to arrest the resorption process might not be possible due to lack of access. 9 Some authors have cautioned there is the possibility of neighbouring teeth tipping or migrating into the space originally occupied by the intruded tooth, resulting in space loss. 16 For intruded teeth with incomplete roots, repositioning by orthodontic means is recommended only if the tooth does not show signs of spontaneous re-eruption in a few weeks and surgical repositioning is recommended if the tooth is intruded more than 7 mm. 15 Some of the common sequelae following intrusion injuries include pulp necrosis, marginal bone loss, inflammatory root resorption and replacement resorption. The appearance of sequelae depends on the degree of root development, age of the patient and degree of intrusion. There is a lower incidence of pulp necrosis and root resorption in immature teeth as the greater contact area between the pulp and periodontal ligament in these cases favour revascularization. 3 Also, the more resilient alveolar bone in these patients cushions the blow to the periodontal ligament, thereby reducing subsequent damage. 3,16 In our case, there were clinical signs of pulp necrosis and radiographic signs of external root resorption by the fifteenth day following the trauma. At this time, as the tooth was still intruded, a palatal flap was reflected to allow for endodontic access. Following cleaning and disinfection, the canal was filled with calcium hydroxide as it has been shown to be reliable in arresting the resorption process 17,18 and obtaining apical closure. 19 Some authors have reported acceleration in the eruption process following gingivectomy and root canal treatment with a calcium hydroxide based material. 14,20 The acceleration in the re-eruption process has been attributed to the removal of gingival tissue obstructing eruption. 14 In our case, even though no gingivectomy had been carried out, there was acceleration in re-eruption once the root canal was filled with a calcium hydroxide based material. The duration of treatment with calcium hydroxide is another factor that needs to be considered as long-term calcium hydroxide therapy is shown to weaken root dentine, making the tooth more prone to fracture. 21 The ideal duration of maintenance of calcium hydroxide in the canal has still not been established, with some authors recommending the completion of root canal obturation only after radiographic confirmation of the cessation of the resorption process characterized by the 2014 Australian Dental Association 243

V Chacko and M Pradhan re-establishment of the periodontal ligament space and the presence of an intact lamina dura. In our case, the calcium hydroxide dressing was maintained until it was certain the resorption process had ceased. Other authors have suggested the use of mineral trioxide aggregate 22 to overcome the drawbacks of calcium hydroxide and also questioned the possibility of pulp revascularization in an intruded tooth. 7 However, the latter approach needs to be carried out with caution as failure to disinfect the pulpal tissue could hasten the progression of root resorption in a young permanent tooth because of the presence of wide dentinal tubules, which allow for penetration of bacterial irritants. CONCLUSIONS The outcome of this case highlights the possibility of spontaneous re-eruption even in severely intruded permanent incisors with open apices. However, early endodontic intervention following reflection of a mucoperiosteal flap or gingivectomy and regular longterm follow-up are essential for the prevention and management of the numerous possible complications that can occur following this type of injury. REFERENCES 1. Albadri S, Zaitoun H, Kinirons MJ. UK National Clinical Guidelines in Paediatric Dentistry: treatment of traumatically intruded permanent incisor teeth in children. Int J Paediatr Dent 2010;20(Suppl 1):1 2. 2. Andreasen JO, Bakland LK, Matras RC, Andreasen FM. Traumatic intrusion of permanent teeth. Part 1. An epidemiological study of 216 intruded permanent teeth. Dent Traumatol 2006;22:83 89. 3. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 2. A clinical study of the effect of preinjury and injury factors, such as sex, age, stage of root development, tooth location, and extent of injury including number of intruded teeth on 140 intruded permanent teeth. 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Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology Guidelines for the management of traumatic dental injuries. 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012;28:2 12. 16. Neto JJ, Gondim JO, de Carvalho FM, Giro EM. Longitudinal clinical and radiographic evaluation of severely intruded permanent incisors in a pediatric population. Dent Traumatol 2009;25:510 514. 17. Cvek M. Treatment of non-vital permanent incisors with calcium hydroxide II. Effect of an external root resorption in luxated teeth compared with effect of root filling with guttapercha. Odontol Revy 1973;24:343 354. 18. Andreasen JO. Luxation of permanent teeth due to trauma: a clinical and radiographic follow-up study of 189 injured teeth. Scand J Dent Res 1970;78:273 286. 19. Morse DR, O Larnie J, Yesilsay C. Apexification: review of the literature. Quintessence Int 1990;21:589 598. 20. Tronstad L, Trope M, Bank M, Barnett F. Surgical access for endodontic treatment of intruded teeth. Endod Dent Traumatol 1986;2:75 78. 21. Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with gutta percha. A retrospective clinical study. Endod Dent Traumatol 1992;8:45 55. 22. Oliveria TM, Sakai VT, Silva TC, Santos CF, Abdo RC, Machado MA. Mineral trioxide aggregate as an alternative treatment for intruded permanent teeth with root resorption and incomplete apex formation. Dent Traumatol 2008;24:565 568. Address for correspondence: Dr Varghese Chacko Associate Professor Department of Pedodontics and Preventive Dentistry Manipal College of Dental Sciences Mangalore Manipal University Light House Hill Road Mangalore 575001 India Email: varghesetvm@yahoo.co.in 244 2014 Australian Dental Association