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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 56-59

Management of traumatically intruded immature permanent incisor


1 Multiprofile Hospital for Active Treatment “Europe” Ltd; Dental Studio Perfect APMA – IPPMP, Dental Medicine Ltd., Sofia, Bulgaria
2 EO Dent Dental Clinic, Sofia, Bulgaria
3 USHMFS Sofia, Medical University of Pleven, Pleven, Bulgaria
4 Dental Studio Perfect APMA – IPPMP, Dental Medicine Ltd., Sofia, Bulgaria

Date of Submission23-Jun-2019
Date of Decision21-Sep-2019
Date of Acceptance30-Sep-2019
Date of Web Publication05-Feb-2020

Correspondence Address:
Dr. Bistra Blagova
Dental Studio Perfect APMA – IPPMP, Dental Medicine Ltd., “Gen Stefan Toshev”, Street No 1, Sofia 1618
Bulgaria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjos.SJOralSci_49_19

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  Abstract 


Intrusive luxation injuries often result in severe damage to the tooth itself and surrounding tissues. Furthermore, treatment outcome is often unpredictable because of the large number of injury-related variables (such as time passed, patient age, comorbidities and related treatment, and patient cooperation) which influence the choice of treatment and prognosis. This report presents the case of an 8-year-old boy with a severely intruded immature permanent upper incisor combined with missing alveolar socket wall. The treatment option chosen by the parents was to replace the tooth and fix it by glass fibers as splinting material. Four months after the trauma, the tooth was vital and asymptomatic, and radiographic examination showed satisfactory periapical and periodontal healing. The outcome of the presented case highlights the importance of the timely and properly performed management together with the regular long-term follow-ups for the survival rate of severely intruded immature teeth, even with a missing supporting alveolar wall due to the facilitated revascularization through their wide open root foramina.

Keywords: Immature teeth, open apex, oral surgery, tooth intrusion, traumatology


How to cite this article:
Blagova B, Dardanov A, Yanev N, Shekerova S, Galeva H. Management of traumatically intruded immature permanent incisor. Saudi J Oral Sci 2020;7:56-9

How to cite this URL:
Blagova B, Dardanov A, Yanev N, Shekerova S, Galeva H. Management of traumatically intruded immature permanent incisor. Saudi J Oral Sci [serial online] 2020 [cited 2020 Feb 22];7:56-9. Available from: http://www.saudijos.org/text.asp?2020/7/1/56/272993




  Introduction Top


Intrusive luxation is a rare type of dental injury in which the tooth is displaced apically into the alveolar bone by a traumatic force. It comprises 0.3%–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 fibers, pulp tissue, and alveolar bone. When this type of injury occurs in children involving teeth with open apices, there is also a possibility for the tissues in the apical area to be severed and the socket bone to penetrate into 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 re-erupt, 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 preadolescent age group, proper management of the injury and its numerous complications is extremely important for the patient to complete optimum facial and occlusal development.[7]

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.,[8] 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 of a severely intruded young permanent incisor in an 8-year-old patient.


  Case Report Top


An 8-year-old boy reported to our dental praxis with a complaint of pain in the upper anterior region following injury in a swimming pool the same day. According to the parents, there were no episodes of loss of consciousness or discharge from nose or ears following the fall. However, they gave a history of bleeding from the oral cavity, which ceased without any intervention.

On examination, the patient had an abrasive injury to the upper lip that appeared slightly swollen. Intraorally, an ulcer next to the labial frenulum was presented. The upper right central incisor (tooth # 11) appeared to be intruded, with <1 mm of the fractured incisal edge clinically visible and without pulp exposure. The left one (tooth # 21) was missing, and it was not brought by the parents. His orthopantomography showed obliteration of the periodontal ligament space in relation to the intruded tooth and empty socket of tooth # 21 [Figure 1]. The depth of intrusion was measured by detecting the distance from the enamel–cementum junction of tooth # 11 to the interdental alveolar wall of the adjacent incisor, which was 9 mm.
Figure 1: Preoperative orthopantomography

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After discussing different treatment options and possible outcome based on the parents' informed consent, the intruded tooth was surgically repositioned by planned replantation, and it was established that the buccal wall of the socked was missing. The incisor was immobilized by splinting to the neighboring teeth by EverStick®Perio (GC, Japan, approximately 1.1–1.3 mm in diameter silanated e-glass fiber impregnated with bis-GMA and PMMA). The socket of missing left incisor was checked for excluding foreign bodies and bone fragments. The soft tissue wound was sutured. The patient was prescribed antibiotics (amoxicillin, 500 mg, t.i.d) for 5 days and 0.2% chlorhexidine mouthwash for oral hygiene and asked to report after 72 h [Figure 2]. At the subsequent appointment, there were no complaints from the patient nor any pathological changes were clinically detectable. Hence, it was decided to review the patient at regular intervals for radiographic and clinical checking by electric pulp testing of tooth vitality [Figure 3] and [Figure 4]. On examination, by the follow-ups at the 16th, 36th, and 118th day, the tooth was asymptomatic, not tender on percussion, with normal probing depths and did not show any abnormal mobility. The radiographic examination showed satisfactory periapical and periodontal healing. No active inflammatory external resorption nor replacement resorption were detected on the X-ray [Figure 4]. The vitality of the tooth was confirmed by the improving data from the electric pulp tests (Pulp tester C–pulse, Foshan CICADA Technology, China, input DC 9 V, output 80 V, 90 mA) [Figure 3]. The crown of the intruded incisor was restored, and the splinting was removed at the 36th day after the trauma. The patient was advised to report for review every 6 months. By all regular appointments, six check-ups within the first one and a half year following the trauma, there were no pathologic findings established neither clinically nor radiographically. Based on the fluent patient recovery, the child was referred to an orthodontist for management of the dental and occlusal changes following the accident.
Figure 2: A follow-up following 72 h

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Figure 3: An electric pulp testing of tooth vitality: (a) at the 16th day; (b) at the 36th day; (c) at the 118th day

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Figure 4: A follow-up after four months

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  Discussion Top


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 preinjury 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 >6.0 mm have a poorer prognosis with greater chances of pulp necrosis and inflammatory root resorption.[4],[12] In the case presented, the depth of intrusion was 9.0 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.[14] In presented patient, we decided to follow the recommendations of Diangelis et al.[13] in case of tooth intrusion more than 7 mm, namely surgical repositioning and immobilizing it toward neighboring stable teeth using the micromovements limited by their periodontal ligament. Current evidence supports functional semiflexible splints for fixation of replanted teeth. Studies have shown that periodontal and pulpal healing is promoted if the replanted tooth is given a chance for slight motion, facilitating revascularization and therefore nutrition.[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 favor revascularization.[3] Furthermore, 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 neither any clinical signs of pulp necrosis nor radiographic signs of external root resorption by the follow-ups.


  Conclusion Top


The outcome of the presented case highlights the importance of the timely and properly performed management, together with the regular long-term follow-ups, for the survival rate of severely intruded immature teeth even with a missing supporting alveolar wall due to the facilitated revascularization through their wide open root foramina.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Albadri S, Zaitoun H, Kinirons MJ, British Society of Paediatric Dentistry. 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.  Back to cited text no. 1
    
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;22:83-9.  Back to cited text no. 2
    
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. Dent Traumatol 2006;22:90-8.  Back to cited text no. 3
    
4.
Al-Badri S, Kinirons M, Cole B, Welbury R. Factors affecting resorption in traumatically intruded permanent incisors in children. Dent Traumatol 2002;18:73-6.  Back to cited text no. 4
    
5.
Sapir S, Mamber E, Slutzky-Goldberg I, Fuks AB. A novel multidisciplinary approach for the treatment of an intruded immature permanent incisor. Pediatr Dent 2004;26:421-5.  Back to cited text no. 5
    
6.
Sönmez H, Tunç ES, Dalci ON, Saroglu I. Orthodontic extrusion of a traumatically intruded permanent incisor: A case report with a 5-year follow up. Dent Traumatol 2008;24:691-4.  Back to cited text no. 6
    
7.
Chacko V, Pradhan M. Management of traumatically intruded young permanent tooth with 40-month follow-up. Aust Dent J 2014;59:240-4.  Back to cited text no. 7
    
8.
Tsilingaridis G, Malmgren B, Andreasen JO, Malmgren O. Intrusive luxation of 60 permanent incisors: A retrospective study of treatment and outcome. Dent Traumatol 2012;28:416-22.  Back to cited text no. 8
    
9.
Chan AW, Cheung GS, Ho MW. Different treatment outcomes of two intruded permanent incisors – A case report. Dent Traumatol 2001;17:275-80.  Back to cited text no. 9
    
10.
Andreasen FM, Andreasen JO. Luxation injuries. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed.. Copenhagen: Munksgaard Publishers; 1994.  Back to cited text no. 10
    
11.
de Alencar AH, Lustosa-Pereira A, de Sousa HA, Figueiredo JH. Intrusive luxation: A case report. Dent Traumatol 2007;23:307-12.  Back to cited text no. 11
    
12.
Kinirons MJ, Sutcliffe J. Traumatically intruded permanent incisors: A study of treatment and outcome. Br Dent J 1991;170:144-6.  Back to cited text no. 12
    
13.
Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, 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.  Back to cited text no. 13
    
14.
Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Dent Traumatol 2006;22:99-111.  Back to cited text no. 14
    
15.
Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.  Back to cited text no. 15
    
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;25:510-4.  Back to cited text no. 16
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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