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Review article

Management of intrusive luxation injuriesOulis C, Vadiaka.s G, Sisko.s G. Management of inirnsive luxation in-jnries. Endod Dent Trainnatol 1996: 12: 1 l.Vl 19. © Munk.soaard,1996

Abstract-Tianniatic ininision of permanent teetli is a relatively in-fieqnenl but serious t:)'pe ol dental injury, due to the eomplicatedpicture it itivolves. Various treatment approaches have been sug-gested, so far, regarding management o( intrusive luxation. Tech-niques aiming to reposition the intruded tooth include observationfor spontaneous reernption, siugical as well as orthodontic reposi-tioning. However, development olcomplications such as jJulpnecrosis, inllammatory root resorption, replacement resorptiouand ankylosis and loss of marginal bone support makes selection olthe most favorable techniqne controversial. In this paper, a criticalreview of the existing treatment modalities is attempted and treat-ment approaches based on diagnostic parameters that are indica-tive of the severity of an intrusive injnry are presented. Recommen-dations are made after taking into consideration experimental andclinical study findings and observations from other anthor's andour own clinical experience. Two cases of intrusive luxation in chil-dren are presented and management of the dental injuries as well asthe 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: dentaitrauma

George Vadiakas. 22 Kodrou Street.

152 31 Haiandri. Athens. Greece

Accepted November 20.1995

In dental tranmatology, the term traumatic iutru-sion refers to the displacement of a tooth deeperinto the alveolar bone Ibllowitig the application ofa traumatic force. This type of injnry usually in-volves maxillary teeth and is associated with severepnl]xil and periodontal damage and more than of-ten with some degree of alveolar fractttie. Man-agement of tranmatically intruded permanent in-cisois has been controversial due to the stiiallnnmber of systematic studies existed and the com-plicated pictiue of the injury.

The purpose of this paper was to rexiew the ex-isting treatment schemes for intrusive hixationand categorize the different aj^pioaches based ondiagnostic criteria. Two cases of intrusive injurieswill be presented and management of the compli-cations which occuried will be discttssed.

Review of literature

Intrusive luxation is a commoti type of dental inju-ries in the primaiT dentition; howe\er. it occurslar less frequently in permanent incisors. Intrusiveinjuries are a most serious and difficult to managegroup of dental injuries due to the se\ere com-plications tliat usually follow. The complicationsincltide pulp nectosis, inllamtnatory toot resorp-lion, ankylosis and replacement resolution, andloss of marginal bt)ne support (1).

In the dental literature different treatment ap-proaches have been stiggested ibr the manage-ment of intrusive luxation injmies. However, disa-greement exists regatding the tnost la\orable ap-l^roach to bring intnided teeth iiack to their nor-mal position. Ihe techniques suggested include

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oljscrvation Ibr iceriiption, suigical repositioningand orthodontic rc|jositioning, Obseivation forspontaneous reeiu|Dtion has been suggested as thetreatment of choice, leased on tlie fact that manyof these teetli particnlarly the ones with incom-plete rool formation do reeru]3t on their own (2,3). A serious complication one is faced with fol-lowing this treatment choice is incidence o( puljjnecrosis and loot resorption in cases wliere no sig-nificant amount of eruption occtirs. Andreasen etal. (4) leport a ();?% incidence of ptilp necrosis ina sample of 24 inti nrled teeth witli an open ajDex,while a 100% incidence was found among ?>1 in-truded teeth with a closed apex. To overcome thisproblem, surgical exposure of the intruded tootlicrown by means of a gingivectomy has been sug-gested, to gain access to tlie loot canal wliile wait-ing for spontaneous reeruption (3, 5). However,the esthetic problem tliat results from tlie alveolarosseous defect, commonly present in cases of se-vere intrusion, often recjiiires correction at theend of sj^ontaneous leeruption. Fiu'thermore,Turley et al. (6) liave shown that ankylosis occursin the initial stages following the injury, particu-larly in severe intrusion. A 24% incidence of anky-losis has been reported by Andreasen et al. (4).The above Iindings indicate the risk for develop-ing complicati(jns in cases where observation forspont;meous reeruption is recommended espe-cially when the intrtision is severe. Taintor et al.(7) recommended the application of orthodonticforces for repositioning ol the tooth if no eritptionoccurs after 2 months of observation. However,the lack of eruption during tlie observation peiiodinvolves a rutmber of pro!)lems including pulj:)necrosis, root resporption and ankylosis.

Contiai"y to the conservative approach of Obser-vation fbi- reeruption, immediate surgical reposi-tioning of the intruded tooth has been suggestedby Skieler (8). However, tliis treaUiient approachhas been associated with a higli incidence of anky-losis, pulp necrosis and especially loss of marginalbone (1).

External root rt-sorption has been rejDorted as acomplication of intrusive injuries in 58% of teethwith immature root formation and 70% of teethwith complete root formation (4). In tlie samestudy, marginal bone loss was foimd to be as highas 31% in cases of intrusive luxation. To reducethe incidence of these sequelae and minimize thepossil)ility (or initiation of the ankylosis mecha-nism, Andreasen (1), recommended the immedi-ate application of orthodontic foices to the in-truded tooth. Orthodontic movement renders amore biological way of repositioning the tooth.With this technique, access for toot canal treat-

ment can be established early enough, i.e. withinthe fust 2-3 weeks after the injury, so that inflam-matory lesorption can be pievented or treated ifinitiated (9). Following pulp extirpatit)n, a cal-ciiuii hydroxide paste should be ]Dlaced in the rootcanal to preveiU rool resorption. In teetli withcomplete root foiiiiation calcium hydroxideshould remaiu in the canal as an interim dressingtnuil periodontai healing is established ladio-giapliically. Completion of the endodontic treat-ment shoulfl then follow. In teeth with an openapex calcium hydroxide remains in tlie canal untilthe root formation is completed or an apical hardtissue barriei' is establishefl. Orthodoiuic reposi-tioning of the intruded tootli has been suggestedas the treatment of choice for both immatiu'e andniattire teetli (10).

To stttdy the effect of orthodontic fbrces on in-trttded teeth, first premolars with a complete rootdevelopment were tratimatically intruded in an in-vestigation conducted in dogs (6). 5-() days fbllow-ing the traumatic iutiusion orthodontic extrusivefbrces were applied on halfOf the teeth while theother half left to erupt on tlieir own. Tlie authorsnoticed that with less severe intrusive injuries, or-thodontic extrtision facilitated repositioning ofthe displaced teeth. However, ankylosis and re-]3lacement resoiption occurred in teetli with se-vere intrusive luxation, regardless of orthodontictraction. In anotlier study conducted in dogs, Tur-ley et al. (11) have sliown that luxation of immo-bile trauiuatically intruded teetli, befbre the ajDijli-catiou of oitliodontic forces, facilitated the extru-siou of tlu'se tc-eth preventing ankylosis from be-ing established.

(iliuical studies or reports conducted on intru-sive luxation management have not taken intoconsideration clinical parameters that uuderliuethe severity of a case, sucli as the degiee of intrti-sion and the mobility of the intruded tooth. Sincesevere intrtisive injuries are associated witli severetrauma in the periodontai ligament, the alveolarbone and the ptilp, one would expect develop-ment of com]3lications to be more probable.Therefore, a diffeient management approachsliould apply in these cases compared to cases wilhirriniiiial iuir iisiou. Based on findings from the ex-isting literattiie presented earlier in the papei, ob-servation for spontaneous reeruption is suggestedin cases with minimal irUr usion, while inuiiediatea]D|)Iication of orthodontic extrusive fbrces is sug-gested in cases of severe intrusion. Sucli an ap-]3r()a< li will facilitate the rapid leer uplion of theiutrtided tooth and the early endodontic treat-ment and act preventively in the initiation of anky-losis. Luxation of the intituled tooth l)efbie aj ply-

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Intrusive luxation management

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 al 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 pre-vent onset of ank\'losis.

Case report 1

The first case report involved a lO-year- old Cauca-sian female who was r efer red lo a pedialric dentalpractice for the treaUiient of a dental tratimaticinjury. The patieut was injured alter falling from abicycle, and was transferred to a hospital emer-gency clinic where a pliysical examination wascompleted. She had no injuries other tlian theoral injuries and c ame to o\ir clinic one day aftertlie accidenl.

The medical history was tmeventltil while ex-traoral examination r-evealed an edematoiis upperlip with minor facial abrasions, luiraoral soft tisstteexamination revealed a laceration at the inner as-pect of the upper lip. The riglii maxillary lateral in-cisor was intruded approximately 4-5 mm and hadsuffered a fiacttire involving the enamel and den-tin and extending into the gingival sulcus. Thetootli had a slightly iiur eased mobilitv. hi addition.

a fracture involving the enamel and deruin was ob-served in the right maxillary central incisor. Thislooth was not displaced but had a +3 mobility (mo-bility scale 0-3) (subluxatiou) (Fig. 1). Radio-graphs obtained did not show evidence of root frac-tures and confirmed the clinical diagnosis of inlru-sion and crown fractures. Both traumatized teethhad complete root development and there was noclinical or- radiographic evidence of other injuries.

Two sutures were placed iu the upper lip afterirrigation with saline, while band-aid compositeswere bonded to the fractured incisors. To allow fbrperiodontai healing of the sublnxated incisor, asplint extending fioni the right permarieul centralincisor- lo the primary left canine was placed, usinga piece of orthodt)ntic wire attached to the teethwith resin. To reposition the intruded lateral inci-sor, an orihodontic buitou was bonded to thattootli wliile orthodontic attachmenls were placedon the lower anterior leeth which were stabilizedwith a round wire. Elastic traction was appliedfrom the maxilfarv lateral lo the lower teeth to de-liver an extrusixe fbrce (Fig. 2). The patieni \vasadvised lo change the elastic twice dailv.

At one week |3ost-trauma, the spliui was re-moved. Two weeks fbllowing the injtiry, a radio-gr-aphic examination revealed a periapical radi-olucenc\ at lhe apex of the intruded lateral andslight external resorpiiou was evidi-rrt in tlie api-cal area of this tooth. At this time lire tooth wasadeqtialel)' extruded to allow endodontic access.The ptilp was extirpated, the canal instrumentedand calcium lndr-oxide placed tinder rubber damisolation. Radiographic examination also indi-cated external resorptiou of lhe right maxillarvcentral incisor; A pulpectomv was per-fbrined fol-lowed by a calcium hvdroxide dressiug of the ca-nal.

After- Ibur- weeks of orthodontic ireaUnent. the

(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 periapicalradioluscency and fxleniai resoi'iuioii on laleral, cervical resorplion on ctnlral . •//;. Radiographic view afler apicoeclonn- on laleraland 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. Atthat lirrre lire fraclure line extended just below thegingival line and restoration of both incisors wasperforrrrefl using lhe acid-etch composite resintechni<|ue (Eig. 3). A 0.01 (i stainless steel (SS) wirewas Ixjnded lo the maxillary anterior leelh lor 3months for- releulion purposes.

The (-alcirmr hydroxide paste ir-r the (arials wasreplaced ever-)' 2-3 months. Eleven months fbllow-ing tlie injury, the canals ol the central and lateralincisors were obluraled wilh gutta-perxha audCirossmann paste.

One year after the lirial obturatiou a radio-graphic examination showed a large radiolusceniarea extending in the dislal as]3ect and ]Deriapicalarea of the right maxillary laleral incisor- root, aswell as external resorption in lhe cervical area ofthe riglu maxillary central incisor- (Fig. 4). Clini-cally, the two incisors demor-rstrated a +2 mobilityand were sensitive to percussion. At that appoint-ment a decision was made for endodontic retreat-men to f bolli incisors and for resection of lhe r-oottip of the lateial incisor and surgical restoration ofthe cervical resorption area of the central incisor(Eig. 4). A follow-up radiograph 8 mouths afterlire suigical pr-ocedtire revealed adequate healingof lhe |:)ei-iodontal tissttes (Eig. 4). Bone Ibr-matiouhad jDr-ogressed ar-ound the rool of lhe laleral iirci-sor and there were no signs of external r-esor-]jtion.

The teeth were asyrirptotic showing a normal mo-bilitv.

Case report 2

Ihe secorrd case report involved an S-year-oldCaucasian male who was subjected to a facialinjtiiy after falling down and hilling his fac-e on arock. The patieni was Ir-ansferi-ed irrmredialely to alocal en-rergency clinic where a physical exam wasperformed and two sutures placed ou the chinand one in the lower- lip. Arilibiolics were pre-scrihed and the jjatieut was r-efeired to a ijediatricdentist fbr dental evaltialion.

lire extraoral examination showed an edema-lous upper and lower lip and abrasions irr lire ]3eri-oral area. Tlie intraoral examination revealed alaceration in the free and altached giugivae me-sially to lhe riglit maxillary central incisor-. Bothlire right maxillary central aud lateral incisor werealwerit. The left maxillary central and laleral inci-sor- demonstr-ated a +2 mobilily withotit being dis-lalaccd, while the anterior segment of the maxil-lary alveolar pr-ocess was extremely mobile iudical-iug an alveolar Iracttire. A radiographic examina-tion rcn'ealed lhat the two incisors, clinically evalti-ated as absent, had been fully intrtided. The radio-graphic examination revealed no root fracttiresand 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 \ d r o x -

i d e I r e a d n e n l . 5 r . O n e \ ' e a i 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 , a j i i c a l s l o p s o n c c n l r a l a n d l a l e r a l i n c i s o r .

maliori, particnlarly for the laterals. Clinical andradiographic assessmeut revealed no maudibtilarIVaclure.

At the initial appoiulmenl the iriiraoral soft tis-sues were irrigated with saline and lwo sultrreswere jalaced iu ilie labial gingivae. l^ue to soft tis-stie edema aud limited moulh opening, ihe pa-tient was dischar-ged wilh )3ain mechcaiion, and asoft diet, and advised lo returu in 3 days.

At the second visit, partial repositioning of theintrtided teelh with forceps uuder local auestliesiawas attempted so ihal attachmenl oldrlhodoniicappliances and application of air extrtrsive force

could be possible. The patient returned tlie fol-lowing day when corUrol of haemorrhage and adry field had been established. Orthodontic- bandswere cemented on the first maxillarv r-nolars, or-ihodorilic btrUons were bonded to the irrirridedteeth, and an 0.01 Sx 0.025 SS r-ectangtrlar wir-ewith a first order- bend was placed or-r the maxillarvteeth. The wire was used for spfiuting ])ui-poses toallcnv for- healing of the alveolar f Vacture aud peri-odonlal healing of the subluxaled teeth. At thesarrre time, the wire ser\-ed as anchorage to apph-elastic forces to the itilruded teelh. The patient re-ttirrred cner-y 5 daxs to rejilace the elastics used to

Fig. 6. Partial reposilionini;ol inlruded leelh willi forecpis./'/IL;'. /Or thodon l i c appliances nsed lor spliming pniposes and

applicalion of exirnsive lorces.

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Oulis et al.

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< i r 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 follow-ing inser lion of the aj^pliance, a radiographic ex-amination revealed external resorption lacunae atthe root surfaces of both inli-uded teeth. At thisappointriient, the pulp was extirpated in bothteeth. The canals were instrumented and dressedwith a calcium hydroxide paste. The orthodonlicextrusion was corrrpleted in 3 weeks and the splirilwas removed after 2 months. At that time all in-jured teetli were asymptomatic. They exhibited anormal mobility and the alveolar bone was stable.

In order to correct the crown and root positionof tlie injured teeth and improve tlie alveolarborie morphology of lire arrterior segment, brack-ets were bonded on the maxillary incisors. Eollow-ing a wire sequence from a 0.016 Niti to a rectan-gular arcliwire, the position of the intruded teethand the bone morphology were improvecl.

Periodic radiograyjliic fbllow-up examinationsshowed arrestment of the root resorption aud con-tinuation of the root development. One year post-trairma, apical stops had formed in the intrudedcenttal and lateral incisors.

Discussion

In the cases reported here, manageineut wasbased on treatment recommendaticjns presentedin lire first part of the paper. The l'ecommenda-tions were based on existing clinical and experi-mental sludy rmdings, various treatmentmodalities suggested and observations from ourown clinical exjierience. However-, the complica-tions encotinlered indicaled lhat the ideal treat-ment is yet to be fbund.

In the first patient, a moderate degree of intr-u-sion was present and immediate orthodontic trac-tion was undertaken. The tootli thai had a slightlyincreased mc:)bility after- the irijtuy and a closedapex responded favorably to orthodontic forces .Orthodontic attachments were Ijcinded to thelower incisors so tliat rapid extrusion of the toothcould be accomplished to allow foi- an early endo-dontic access.

The complications encountered in this case in-cliided an early as -well as a late sequela. Eirst, ex-lerrial r-ooI r-es()r-|)lion was nolic-ed, while later- cer--vical resorptiorr as well as a j^eriapical radiohisccntlesion clevelojjc-cl. fo irilerr-ti|5t the progressing ex-teriral root rc'sor-jjlion in lhe iraumatized teeth,calcium hydroxide treatment was initiated. («il-citim hydroxide has been shown to arrest infiam-matory resorption wilh high degi'ee of success (12,13). It has been suggested thai in cases of avulsionarid intrusive luxation of mature teeth, calcium hy-droxide slic:)uld not be used until the periodor-rtalligament repair has been comjDleled (14). A po-tential harmful effect c)u llie periodonlal ligamentallegedly might lead to localized ankylosis and re-placement resorption (15). However, a review oftlie existing clinical investigations that have stud-ied lhe long term prognosis of intruded teethIrealc-d wilh calcium hydroxide do uol supporlthis theory (12, Hi). Aukylosis has been a relativelycomrrrori posl-lrauma sequela iu intrusive luxa-tion, particularly in severe cases, due to injuries ofthe periodontai fi.ssiies. Cvek (16) has shown thatankylosis after an intrusive injury occurs beforetreaurient wilh calcitirn hydroxide, indicating lhatit is the periodontai injury rather- tlian the calciumliydrc:)xicle which is respcjnsible for its occurrence.Eurthennore, the recommended immediate or-thodontic traction of the intruded teeth may wellact preveutlvely iu aukylosis initiation. One shonldalso not forget that during the orthodoritic mcjve-ment a period of 2-3 weeks for iuilial periodoutalhealing is available, befbre calcium hydicjxideIreaUnent begins.

The developmerU of late post-trauma sec]uelaeiu the first patient, ajjproximately 2 years after the

118

inilial injiir-)', indicated the need for a long follow-up period for intruded teeth. Cei-\-ical resorptionis a type of inflammator-y resorplion and is seen inmost instances as a late complicalion fbllcwingdental trauma. According to Tronstad (17), an iri-jtiry to the cervical part of the periodontai liga-menl may lead lo initiation c->f resorbing activit\' inthe area. Continuous stimulatic:)n of the r-esorbingcells by bacterial products deriving usually fromthe giugival sulcus results iu cervical resor-)Mion.This was sup])orted by the pr-esent findings in thatthe cervical resorption develo|3ed afler the endo-dotitic treatment had been corrri:)leled. indicatingthat the resc)r-|3tive process was sirstaiired by extra-canal bacterial prc:)ducts. This coruplicatiou wasmairaged by surgically exjjosing the cervical rootsurface and removing the graruilation li.ssue. Althe same appointmerrt an apicoectoinv was per-formed on the intruded lateral incisor to treat theapical periodonlitis.

In the second case report, the Iranmalized inci-sors sustained a severe degree of inlrrisiori that re-sulted in clinical absence of the tc^oth crowns. Ma-jo r problems encounlered were the scn'erity of in-trusion, the simullaueous occurrence of an alveo-lar fracttire lhat resulled in an alveolar bone defect,as well as the iirmiattirily of lhe iulruded teelh. Iusuch a case, irrrniediale application of Orthodont icforces is not possible because of lhe irial)ilit)' tobond orihodontic allachmeriis. In addilion, ortho-dontic manipulatiou was firrlher c-omplicated b\'management of ihe alveolar fracture' |)reseul. Theintruded teeth had to be partialh rc-positioued withforceps before brackets could be ])laced.

The alveolar osseous defect caused by the trau-matic force in the area of the intrtided teetli cre-ated an esthetic problem for llie palienl. Perio-donlal surgical |)r-ocednr-es are usually necessary tocorrect such a problem. However, in lhis case, weelected lo orthodontically correct tlie position ofthe maxillary incisors before any surgical proce-dure was altenr|3tecl. By correcting the position ofthe r-oot of the leelh, we oblained a more pleasing-surface form of the alveolar bone through themechanism of bone reniodelliiig. During the or-thodontic irealnieul, a remarkable improvenierUof Ihe osseous stirface was noticed, nc^arly elimi-nating the problem. Although the patient is stillunder treatment, we believe thai a surgical correc-tiou of lhe alveolar bone will not be necessary inthe futuic'.

Teeth tlial sustain severe trauma in a relalivelvearly develc)]3nrerrlal rool stage always |)r'esenl wilha guarded prognosis, l h e degree of rool immatti-rity makes any apexification altempt difficiill. Fur-ther-more, even if tlie ajx-xifkatiou procedure is

Intrusive luxation management

successful, we end up \vilh a looth that has weakroot dentinal walls that ma\ be subject to a futurefraclure. Cvek (16), in a retrospective study, fbtrrida high frequency of cervical root fractures in teeththat had undergone calcium lndroxide apexiflca-tiou treatment after- luxation injuries. The fracttirefrequency increased with lire degree of immalnrit)'o{' tlie roots and was as high as 77%) among teethwith the least developed roots.

References

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12. (AKK M. Treatment of non-vital peinianenl incisors wilhcalcium hvdtoxide 11. F.ITecl ol an external root resor|nionin hixated teelh lomjiared wilh elTed of root flllitig wilhgntta-petcha. Odoutot Hn<y t97.H: 2-/; 34.V."i4.

\'^. ANIIREASEN JC^. I.itxation c-il' pertnanenl leelh dne totrauma: a clitiical atid radiogtaphic follow-up stud\ ol 1S9itijnred teeth. Semit J Dent Re.s 1970: 7<S'.-273-86.

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

Hi. (AKK M . Prognosis of luxated non-vital maxillar\ incisotstreated with calciut-ii hvdroxide and ftUed with gvitta-percha. .\ relrospedix'e clinical sindv Fndod Dent 'Ihiiim/i-tot 1992: ,S'.-|.^-.^).^.

17. IRONSIAD f,. Rool i'esorj)iion-c'liolog-\. lernrinologA' andiliuical nianileslalions. l-'.ndiut Dent Tniunuitol 1988: -/. 2 1 1 -

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