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Review article

Management of intrusive luxation injuries

Oulis C, Vadiaka.s G, Sisko.s G. Management of inirnsive luxation injnries. Endod Dent Trainnatol 1996: 12: 1 l.Vl 19. Munk.soaard, 1996 Abstract-Tianniatic ininision of permanent teetli is a relatively infieqnenl but serious t:)'pe ol dental injury, due to the eomplicated picture it itivolves. Various treatment approaches have been suggested, so far, regarding management o( intrusive luxation. Techniques aiming to reposition the intruded tooth include observation for spontaneous reernption, siugical as well as orthodontic repositioning. However, development olcomplications such as jJulp necrosis, inllammatory root resorption, replacement resorptiou and ankylosis and loss of marginal bone support makes selection ol the most favorable techniqne 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 injnry are presented. Recommendations are made after taking into consideration experimental and clinical study findings and observations from other anthor'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. C. \ G. \/adiakas\ G. Siskos^
Departments of 'Pediatric Dentistry. 'Endodontics. University of Athens. Greece

Key words: intrusion injury: iuxation injury: dentai trauma George Vadiakas. 22 Kodrou Street. 152 31 Haiandri. Athens. Greece Accepted November 20.1995

In dental tranmatology, the term traumatic iutrusion refers to the displacement of a tooth deeper into the alveolar bone Ibllowitig the application of a traumatic force. This type of injnry usually involves maxillary teeth and is associated with severe pnl]xil and periodontal damage and more than often with some degree of alveolar fractttie. Management of tranmatically intruded permanent incisois has been controversial due to the stiiall nnmber of systematic studies existed and the complicated pictiue of the injury. The purpose of this paper was to rexiew the existing treatment schemes for intrusive hixation and categorize the different aj^pioaches based on diagnostic criteria. Two cases of intrusive injuries will be presented and management of the complications which occuried will be discttssed.

Review of literature Intrusive luxation is a commoti type of dental injuries in the primaiT dentition; howe\er. it occurs lar less frequently in permanent incisors. Intrusive injuries are a most serious and difficult to manage group of dental injuries due to the se\ere complications tliat usually follow. The complications incltide pulp nectosis, inllamtnatory toot resorplion, ankylosis and replacement resolution, and loss of marginal bt)ne support (1). In the dental literature different treatment approaches have been stiggested ibr the management of intrusive luxation injmies. However, disagreement exists regatding the tnost la\orable apl^roach to bring intnided teeth iiack to their normal position. Ihe techniques suggested include

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Oulisetal.
oljscrvation Ibr iceriiption, suigical repositioning and orthodontic rc|jositioning, Obseivation for spontaneous reeiu|Dtion has been suggested as the treatment of choice, leased on tlie fact that many of these teetli particnlarly the ones with incomplete rool formation do reeru]3t on their own (2, 3). A serious complication one is faced with following this treatment choice is incidence o( puljj necrosis and loot resorption in cases wliere no significant amount of eruption occtirs. Andreasen et al. (4) leport a ();?% incidence of ptilp necrosis in a sample of 24 inti nrled teeth witli an open ajDex, while a 100% incidence was found among ?>1 intruded teeth with a closed apex. To overcome this problem, surgical exposure of the intruded tootli crown by means of a gingivectomy has been suggested, to gain access to tlie loot canal wliile waiting for spontaneous reeruption (3, 5). However, the esthetic problem tliat results from tlie alveolar osseous defect, commonly present in cases of severe intrusion, often recjiiires correction at the end of sj^ontaneous leeruption. Fiu'thermore, Turley et al. (6) liave shown that ankylosis occurs in the initial stages following the injury, particularly in severe intrusion. A 24% incidence of ankylosis has been reported by Andreasen et al. (4). The above Iindings indicate the risk for developing complicati(jns in cases where observation for spont;meous reeruption is recommended especially when the intrtision is severe. Taintor et al. (7) recommended the application of orthodontic forces for repositioning ol the tooth if no eritption occurs after 2 months of observation. However, the lack of eruption during tlie observation peiiod involves a rutmber of pro!)lems including pulj:) necrosis, root resporption and ankylosis. Contiai"y to the conservative approach of Observation fbi- reeruption, immediate surgical repositioning of the intruded tooth has been suggested by Skieler (8). However, tliis treaUiient approach has been associated with a higli incidence of ankylosis, pulp necrosis and especially loss of marginal bone (1). External root rt-sorption has been rejDorted as a complication of intrusive injuries in 58% of teeth with immature root formation and 70% of teeth with complete root formation (4). In tlie same study, marginal bone loss was foimd to be as high as 31% in cases of intrusive luxation. To reduce the incidence of these sequelae and minimize the possil)ility (or initiation of the ankylosis mechanism, Andreasen (1), recommended the immediate application of orthodontic foices to the intruded tooth. Orthodontic movement renders a more biological way of repositioning the tooth. With this technique, access for toot canal treatment can be established early enough, i.e. within the fust 2-3 weeks after the injury, so that inflammatory lesorption can be pievented or treated if initiated (9). Following pulp extirpatit)n, a calciiuii hydroxide paste should be ]Dlaced in the root canal to preveiU rool resorption. In teetli with complete root foiiiiation calcium hydroxide should remaiu in the canal as an interim dressing tnuil periodontai healing is established ladiogiapliically. Completion of the endodontic treatment shoulfl then follow. In teeth with an open apex calcium hydroxide remains in tlie canal until the root formation is completed or an apical hard tissue barriei' is establishefl. Orthodoiuic repositioning of the intruded tootli has been suggested as the treatment of choice for both immatiu'e and niattire teetli (10). To stttdy the effect of orthodontic fbrces on intrttded teeth, first premolars with a complete root development were tratimatically intruded in an investigation conducted in dogs (6). 5-() days fbllowing the traumatic iutiusion orthodontic extrusive fbrces were applied on halfOf the teeth while the other half left to erupt on tlieir own. Tlie authors noticed that with less severe intrusive injuries, orthodontic extrtision facilitated repositioning of the displaced teeth. However, ankylosis and re]3lacement resoiption occurred in teetli with severe intrusive luxation, regardless of orthodontic traction. In anotlier study conducted in dogs, Turley et al. (11) have sliown that luxation of immobile trauiuatically intruded teetli, befbre the ajDijlicatiou of oitliodontic forces, facilitated the extrusiou of tlu'se tc-eth preventing ankylosis from being established. (iliuical studies or reports conducted on intrusive luxation management have not taken into consideration clinical parameters that uuderliue the severity of a case, sucli as the degiee of intrtision and the mobility of the intruded tooth. Since severe intrtisive injuries are associated witli severe trauma in the periodontai ligament, the alveolar bone and the ptilp, one would expect development of com]3lications to be more probable. Therefore, a diffeient management approach sliould apply in these cases compared to cases wilh irriniiiial iuir iisiou. Based on findings from the existing literattiie presented earlier in the papei, observation for spontaneous reeruption is suggested in cases with minimal irUr usion, while inuiiediate a]D|)Iication of orthodontic extrusive fbrces is suggested in cases of severe intrusion. Sucli an ap]3r()a< li will facilitate the rapid leer uplion of the iutrtided tooth and the early endodontic treatment and act preventively in the initiation of ankylosis. Luxation of the intituled tooth l)efbie aj^ply-

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Intrusive luxation management

a fracture involving the enamel and deruin was observed in the right maxillary central incisor. This looth was not displaced but had a +3 mobility (mobility scale 0-3) (subluxatiou) (Fig. 1). Radiographs obtained did not show evidence of root fractures and confirmed the clinical diagnosis of inlrusion and crown fractures. Both traumatized teeth had complete root development and there was no clinical or- radiographic evidence of other injuries. Two sutures were placed iu the upper lip after irrigation with saline, while band-aid composites were bonded to the fractured incisors. To allow fbr periodontai healing of the sublnxated incisor, a splint extending fioni the right permarieul central incisor- lo the primary left canine was placed, using a piece of orthodt)ntic wire attached to the teeth with resin. To reposition the intruded lateral incisor, an orihodontic buitou was bonded to that tootli wliile orthodontic attachmenls were placed on the lower anterior leeth which were stabilized with a round wire. Elastic traction was applied from the maxilfarv lateral lo the lower teeth to deliver an extrusixe fbrce (Fig. 2). The patieni \vas advised lo change the elastic twice dailv. At one week |3ost-trauma, the spliui was removed. Two weeks fbllowing the injtiry, a radiogr-aphic examination revealed a periapical radiolucenc\ at lhe apex of the intruded lateral and slight external resorpiiou was evidi-rrt in tlie apical area of this tooth. At this time lire tooth was adeqtialel)' extruded to allow endodontic access. The ptilp was extirpated, the canal instrumented and calcium lndr-oxide placed tinder rubber dam isolation. Radiographic examination also indicated external resorptiou of lhe right maxillarv central incisor; A pulpectomv was per-fbrined followed by a calcium hvdroxide dressiug of the canal. After- Ibur- weeks of orthodontic ireaUnent. the

Fis;.

I. l i i l i a t i r a l v i e w o l l i a m i i a l i / c d I c c l l i a l i n i l i a l \ i s i i .

Fig. 2. O i t h o d o n l i c c x i r u s i t ) n o f i h c i i i i r u d c c t l a l e r a l ii

ing orihodonlic forces may be considered to prevent onset of ank\'losis.

Case report 1

The first case report involved a lO-year- old Caucasian female who was r efer red lo a pedialric dental practice for the treaUiient of a dental tratimatic injury. The patieut was injured alter falling from a bicycle, and was transferred to a hospital emergency clinic where a pliysical examination was completed. She had no injuries other tlian the oral injuries and c ame to o\ir clinic one day after tlie accidenl. The medical history was tmeventltil while extraoral examination r-evealed an edematoiis upper lip with minor facial abrasions, luiraoral soft tisstte examination revealed a laceration at the inner aspect of the upper lip. The riglii maxillary lateral incisor was intruded approximately 4-5 mm and had suffered a fiacttire involving the enamel and dentin and extending into the gingival sulcus. The tootli had a slightly iiur eased mobilitv. hi addition.

(oiiiposik- rosin.

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Oulisetal.

l''ifj;. 4. Rarliographic coinplic alion and liralnicnl srqucncr. tii. OIK- year al'ler <il)liii aiiciii wilh i;iuia-|>ci-cha: I-aigc periapical radioluscency and fxleniai resoi'iuioii on laleral, cervical resorplion on ctnlral. //;. Radiographic view afler apicoeclonn- on laleral and resloration of cervical resoiplive area on central. 4e. Eighl nionlhs ;xller surgical procednre: Mealing ol periapical radiokis-

cencv-

extrusion of the lateral incisor- was compleled. At that lirrre lire fraclure line extended just below the gingival line and restoration of both incisors was perforrrrefl using lhe acid-etch composite resin techni<|ue (Eig. 3). A 0.01 (i stainless steel (SS) wire was Ixjnded lo the maxillary anterior leelh lor 3 months for- releulion purposes. The (-alcirmr hydroxide paste ir-r the (arials was replaced ever-)' 2-3 months. Eleven months fbllowing tlie injury, the canals ol the central and lateral incisors were obluraled wilh gutta-perxha aud Cirossmann paste. One year after the lirial obturatiou a radiographic examination showed a large radiolusceni area extending in the dislal as]3ect and ]Deriapical area of the right maxillary laleral incisor- root, as well as external resorption in lhe cervical area of the riglu maxillary central incisor- (Fig. 4). Clinically, the two incisors demor-rstrated a +2 mobility and were sensitive to percussion. At that appointment a decision was made for endodontic retreatm e n t o f bolli incisors and for resection o f l h e r-oot tip of the lateial incisor and surgical restoration of the cervical resorption area of the central incisor (Eig. 4). A follow-up radiograph 8 mouths after lire suigical pr-ocedtire revealed adequate healing of lhe |:)ei-iodontal tissttes (Eig. 4). Bone Ibr-matiou had jDr-ogressed ar-ound the rool o f l h e laleral iircisor and there were no signs of external r-esor-]jtion.

The teeth were asyrirptotic showing a normal mobilitv.

Case report 2

I h e secorrd case report involved an S-year-old Caucasian male who was subjected to a facial injtiiy after falling down and hilling his fac-e on a rock. The patieni was Ir-ansferi-ed irrmredialely to a local en-rergency clinic where a physical exam was performed and two sutures placed ou the chin and one in the lower- lip. Arilibiolics were prescrihed and the jjatieut was r-efeired to a ijediatric dentist fbr dental evaltialion. lire extraoral examination showed an edemalous upper and lower lip and abrasions irr lire ]3erioral area. Tlie intraoral examination revealed a laceration in the free and altached giugivae mesially to lhe riglit maxillary central incisor-. Both lire right maxillary central aud lateral incisor were alwerit. The left maxillary central and laleral incisor- demonstr-ated a +2 mobilily withotit being dislalaccd, while the anterior segment of the maxillary alveolar pr-ocess was extremely mobile iudicaliug an alveolar Iracttire. A radiographic examination rcn'ealed lhat the two incisors, clinically evaltiated as absent, had been fully intrtided. The radiographic examination revealed no root fracttires and showed incisors with very immattire root Ibr-

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Intrusive luxation management

I'ig.

">. R a d i o g i a p l i i c I r e a l i n e n i s e c i i i e n e e . T , / . l u l l i n i r n s i c m o l c c n l i a l . l i i d l a l e i a l i n c i s o r , ''ti. l ' n l | ) e x t i r p a l i o n a n d ( a l c i n n i

h\drox-

i d e I r e a d n e n l . 5r. O n e \'eai p o s l - l r a u m a : ( i o i i l i n i i a l i o i i o l < a l i - i u n i h \ d r ( ) \ i d e

i r e a l n i e n l , ajiical s l o p s o n c c n l r a l a n d laleral incisor.

maliori, particnlarly for the laterals. Clinical and radiographic assessmeut revealed no maudibtilar IVaclure. At the initial appoiulmenl the iriiraoral soft tissues were irrigated with saline and lwo sultrres were jalaced iu ilie labial gingivae. l^ue to soft tisstie edema aud limited moulh opening, ihe patient was dischar-ged wilh )3ain mechcaiion, and a soft diet, and advised lo returu in 3 days. At the second visit, partial repositioning of the intrtided teelh with forceps uuder local auestliesia was attempted so ihal attachmenl oldrlhodoniic appliances and application of air extrtrsive force

could be possible. The patient returned tlie following day when corUrol of haemorrhage and a dry field had been established. Orthodontic- bands were cemented on the first maxillarv r-nolars, orihodorilic btrUons were bonded to the irrirrided teeth, and an 0.01 Sx 0.025 SS r-ectangtrlar wir-e with a first order- bend was placed or-r the maxillarv teeth. The wire was used for spfiuting ])ui-poses to allcnv for- healing of the alveolar f Vacture aud periodonlal healing of the subluxaled teeth. At the sarrre time, the wire ser\-ed as anchorage to apphelastic forces to the itilruded teelh. The patient rettirrred cner-y 5 daxs to rejilace the elastics used to

/'/IL;'. / O r t h o d o n l i c appliances nsed lor spliming p n i p o s e s and Fig. 6. Partial reposilionini;ol inlruded leelh willi forecpis.

applicalion of exirnsive lorces.

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Oulis et al.
Discussion

S .Two months pcxst-trauniu: removal ot spliiil.

Fig.

9. F i x e d ; i p p l i . i i i ( e,s l<ir i m p ) i n ' e i n e m o l i n n u d e i l l e e l h p o -

silion and hone morphology.

deli\'er' lhe oilhodontic force. Fifleen days following inser lion of the aj^pliance, a radiographic examination revealed external resorption lacunae at the root surfaces of both inli-uded teeth. At this appointriient, the pulp was extirpated in both teeth. The canals were instrumented and dressed with a calcium hydroxide paste. The orthodonlic extrusion was corrrpleted in 3 weeks and the spliril was removed after 2 months. At that time all inj u r e d teetli were asymptomatic. They exhibited a normal mobility and the alveolar bone was stable. In order to correct the crown and root position of tlie injured teeth and improve tlie alveolar borie morphology of lire arrterior segment, brackets were bonded on the maxillary incisors. Eollowing a wire sequence from a 0.016 Niti to a rectangular arcliwire, the position of the intruded teeth and the bone morphology were improvecl. Periodic radiograyjliic fbllow-up examinations showed arrestment of the root resorption aud continuation of the root development. O n e year posttrairma, apical stops had formed in the intruded centtal and lateral incisors.

In the cases reported here, manageineut was based on treatment recommendaticjns presented in lire first part of the paper. The l'ecommendations were based on existing clinical and experimental sludy rmdings, various treatment modalities suggested and observations from our own clinical exjierience. However-, the complications encotinlered indicaled lhat the ideal treatment is yet to be fbund. In the first patient, a moderate degree of intr-usion was present and immediate orthodontic traction was undertaken. The tootli thai had a slightly increased mc:)bility after- the irijtuy and a closed apex responded favorably to orthodontic forces . Orthodontic attachments were Ijcinded to the lower incisors so tliat rapid extrusion of the tooth could be accomplished to allow foi- an early endodontic access. The complications encountered in this case incliided an early as -well as a late sequela. Eirst, exlerrial r-ooI r-es()r-|)lion was nolic-ed, while later- cer-vical resorptiorr as well as a j^eriapical radiohisccnt lesion clevelojjc-cl. fo irilerr-ti|5t the progressing exteriral root rc'sor-jjlion in lhe iraumatized teeth, calcium hydroxide treatment was initiated. (ilcitim hydroxide has been shown to arrest infiammatory resorption wilh high degi'ee of success (12, 13). It has been suggested thai in cases of avulsion arid intrusive luxation of mature teeth, calcium hydroxide slic:)uld not be used until the periodor-rtal ligament repair has been comjDleled (14). A potential harmful effect c)u llie periodonlal ligament allegedly might lead to localized ankylosis and replacement resorption (15). However, a review of tlie existing clinical investigations that have studied lhe long term prognosis of intruded teeth Irealc-d wilh calcium hydroxide do uol supporl this theory (12, Hi). Aukylosis has been a relatively comrrrori posl-lrauma sequela iu intrusive luxation, particularly in severe cases, due to injuries of the periodontai fi.ssiies. Cvek (16) has shown that ankylosis after an intrusive injury occurs before treaurient wilh calcitirn hydroxide, indicating lhat it is the periodontai injury rather- tlian the calcium liydrc:)xicle which is respcjnsible for its occurrence. Eurthennore, the r e c o m m e n d e d immediate orthodontic traction of the intruded teeth may well act preveutlvely iu aukylosis initiation. O n e shonld also not forget that during the orthodoritic mcjvement a period of 2-3 weeks for iuilial periodoutal healing is available, befbre calcium hydicjxide IreaUnent begins. The developmerU of late post-trauma sec]uelae iu the first patient, ajjproximately 2 years after the

118

Intrusive luxation management inilial injiir-)', indicated the need for a long followup period for intruded teeth. Cei-\-ical resorption is a type of inflammator-y resorplion and is seen in most instances as a late complicalion fbllcwing dental trauma. According to Tronstad (17), an irijtiry to the cervical part of the periodontai ligamenl may lead lo initiation c> resorbing activit\' in -f the area. Continuous stimulatic:)n of the r-esorbing cells by bacterial products deriving usually from the giugival sulcus results iu cervical resor-)Mion. This was sup])orted by the pr-esent findings in that the cervical resorption develo|3ed afler the endodotitic treatment had been corrri:)leled. indicating that the resc)r-|3tive process was sirstaiired by extracanal bacterial prc:)ducts. This coruplicatiou was mairaged by surgically exjjosing the cervical root surface and removing the graruilation li.ssue. Al the same appointmerrt an apicoectoinv was performed on the intruded lateral incisor to treat the apical periodonlitis. In the second case report, the Iranmalized incisors sustained a severe degree of inlrrisiori that resulted in clinical absence of the tc^oth crowns. Maj o r problems encounlered were the scn'erity of intrusion, the simullaueous occurrence of an alveolar fracttire lhat resulled in an alveolar bone defect, as well as the iirmiattirily of lhe iulruded teelh. Iu such a case, irrrniediale application of Orthodontic forces is not possible because of lhe irial)ilit)' to bond orihodontic allachmeriis. In addilion, orthodontic manipulatiou was firrlher c-omplicated b\' management of ihe alveolar fracture' |)reseul. The intruded teeth had to be partialh rc-positioued with forceps before brackets could be ])laced. The alveolar osseous defect caused by the traumatic force in the area of the intrtided teetli created an esthetic problem for llie palienl. Periodonlal surgical |)r-ocednr-es are usually necessary to correct such a problem. However, in lhis case, we elected lo orthodontically correct tlie position of the maxillary incisors before any surgical procedure was altenr|3tecl. By correcting the position of the r-oot of the leelh, we oblained a more pleasingsurface form of the alveolar bone through the mechanism of bone reniodelliiig. During the orthodontic irealnieul, a remarkable improvenierU of Ihe osseous stirface was noticed, nc^arly eliminating the problem. Although the patient is still u n d e r treatment, we believe thai a surgical correctiou of lhe alveolar bone will not be necessary in the futuic'. Teeth tlial sustain severe trauma in a relalivelv early develc)]3nrerrlal rool stage always |)r'esenl wilh a guarded prognosis, l h e degree of rool immattirity makes any apexification altempt difficiill. Further-more, even if tlie ajx-xifkatiou procedure is successful, we end up \vilh a looth that has weak root dentinal walls that ma\ be subject to a future fraclure. Cvek (16), in a retrospective study, fbtrrid a high frequency of cervical root fractures in teeth that had u n d e r g o n e calcium lndroxide apexiflcatiou treatment after- luxation injuries. The fracttire frequency increased with lire degree of immalnrit)' o{' tlie roots and was as high as 77%) among teeth with the least developed roots.

References
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\b. f IAMMAHSIROM f ,!.. BIOMIOK l.tt. fM-.iciix B. LINDSWH; SF. Kl-

leit of calcium Inch oxide Itealmenl on periodoutal repair

and toot resorptioti. Fndnd Dent Tranmeitol 198(i; 2: 184-89.

Hi. (AKK M . Prognosis of luxated non-vital maxillar\ incisots treated with calciut-ii hvdroxide and ftUed with gvittapercha. .\ relrospedix'e clinical sindv Fndod Dent 'Ihiiim/itot 1992: ,S'.-|.^-.^).^. 17. IRONSIAD f,. Rool i'esorj)iion-c'liolog-\. lernrinologA' and iliuical nianileslalions. l-'.ndiut Dent Tniunuitol 1988: -/. 2 1 1 -

119