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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORTS
Year : 2005  |  Volume : 23  |  Issue : 4  |  Page : 193-197
 

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


1 Department of Prosthodontics,Centre for Dental Education and Research AIIMS, New Delhi, India
2 Department of Orthodontics, Centre for Dental Education and Research AIIMS, New Delhi, India

Correspondence Address:
H Parkash
Department of Prosthodontics,Centre for Dental Education and Research,AIIMS, New Delhi - 29
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.19009

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   Abstract 

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.


Keywords: Dental trauma, Intrusive luxation, Orthodontic etrusion, Tooth fracture


How to cite this article:
Jain V, Gupta R, Duggal R, Parkash H. Restoration of traumatized anterior teeth by interdisciplinary approach: Report of three cases. J Indian Soc Pedod Prev Dent 2005;23:193-7

How to cite this URL:
Jain V, Gupta R, Duggal R, Parkash H. Restoration of traumatized anterior teeth by interdisciplinary approach: Report of three cases. J Indian Soc Pedod Prev Dent [serial online] 2005 [cited 2017 Apr 30];23:193-7. Available from: http://www.jisppd.com/text.asp?2005/23/4/193/19009


The Intrusive luxation or avulsion of anterior teeth in children creates psychological impact on both the parents and the child especially if the injury affects the permanent dentition and involves the loss of extensive tooth structure. The majority of fracture and displacements results from accident, collision, sporting activities, domestic violence, automobile accidents, and assaults and in developmentally disabled individuals.[1] Besides the pain and discomfort from the injury, the child's changed appearance may make him the target for teasing and even ridicule by other children.

Injury can lead to displacement of permanent anterior teeth, rotation and intrusion is more common after injury to the tooth.[2] The combination of intrusive luxation of one teeth and avulsion of another is rare, as illustrated by Andreasen.[3] The reason for this uncommon occurrence may lie within the different mechanism of injury associated with these two types of trauma. It is agreed that intrusive luxation is the result of a direct impact on the incisal edge in an axial direction and the energy in the form of an impact can results in crown fracture. While avulsion is the result from blind impact associated with the high resilience of tooth supporting structure.

Intruded teeth can be treated in three ways,[4] i.e. await spontaneous re-eruption, immediate surgical correction and fixation and orthodontic repositioning. These teeth have a tendency for rapid root resorption, pulpal necrosis and tooth ankylosis. Intruded immature permanent teeth may be left to re-erupt spontaneously unless the intrusion is severe.[5] The complication of ankylosis is seen when the severely intruded teeth are left to re-erupt themselves.[5],[6] If the immature teeth do not show early spontaneous re-eruption or if root apex of the tooth is closed, orthodontic repositioning should be initiated.[7] Andreason et al.[8] found decreased incidence of ankylosis when orthodontic technique was used to reposition the intruded permanent teeth. Surgical repositioning increases the possibility of external root resorption and loss of bone support.

This article describes the restoration of smile of the patients after intrusive luxation of teeth by different treatment options available.


   Case Reports Top


Following cases reported in Department of Dental surgery, at various stages of crown fracture and displacement. Case details are as follows.

Case 1

A 10-year-old girl reported with a history of roadside injury 2-3 months back leading to fracture of upper central incisors. On clinical examination it was seen that both the central incisors sustained a concomitant uncomplicated crown fracture [Figure - 1]. The gingiva around the fractured tooth 11 was inflammed and the tooth was intruded and labially displaced. There was no mobility or tenderness on percussion.

Periapical view showed both the incisors with closed apices and periapical pathology was present. The periodontal space around their root was widened but no root or bone fracture could be detected. On the basis of clinical and radiographic findings following treatment plan was made, i.e. endodontic therapy as soon as possible followed by orthodontic extrusion of intruded teeth with the help of removable appliance to reposition the tooth, clinical and radiographic follow up of both central incisors and porcelain fused to metal crown on both the central incisors (11 and 21).

Endodontic therapy was done in both the central incisors the root canal were debrided and obturated with gutta-percha points. Orthodontic extrusion was started 3 months after the endodontic treatment to allow bone healing in periapical region.

Extrusion was planned with the help of removable appliance. A cast post and core with hook on the core was fabricated and cemented in tooth 11. Alginate impression for removable appliance was taken 24 h after post and core cementation. A removable orthodontic appliance (Hawley appliance) was constructed, with a loop in the labial bow in the region of tooth 11 and ¼ in. elastic was used to exert light extrusion force [Figure - 2]. Patient was advised to change elastic on every second day.

Approximately 3 months after the initiation of orthodontic treatment extrusion of the tooth was completed [Figure - 3]. After that same appliance was used continuously for further 2 months as retainer.

Prosthodontic rehabilitation was done after completion of orthodontic treatment. Porcelain fused to metal crown was given on both the central incisors to provide good esthetics [Figure - 4].

Case 2

A 9-year-old girl reported with a history of fall few weeks back, which lead to fracture of upper left central incisor. On clinical examination two-thirds of the coronal tooth structure was fractured and the fracture line was below the gingival margin on palatal side [Figure - 5]. There was no tenderness or mobility of tooth on percussion.

Radiographic examination of 21 showed closed root apex with periapical pathology. There was no sign of root fracture. On the basis of clinical and radiographic finding a definitive treatment plan was made.

Endodontic therapy was instituted in the 21. The root canal was derided and filled with gutta-percha points. Orthodontic extrusion was started after endodontic treatment to move the fracture line at the gingival level on palatal side. Extrusion was done with the help of removable appliance in the same manner as in the pervious case [Figure - 6]. All ceramic crown was given on tooth 21 to provide good esthetic results [Figure - 7].

Case 3

A 9-year-old boy reported 16-18 h after injury to the anterior teeth. Clinical examination showed laceration of the upper lip with moderate edema. Tooth 11 was rotated and intruded. Tooth 12 and 21 were avulsed [Figure - 8]. Periapical radiograph revealed close apices. There was no pulpal or periapical pathosis in tooth 11. Periodontal space around tooth 11 was reduced but no root or bone fracture was detected. Socket of 12 and 21 was clean with no tooth remnant. Emergency treatment consisted of cleaning the soft tissue, prescribing antibiotic and instructions for maintenance of oral hygiene. The first stage of treatment consisted of orthodontic extrusion of the intruded tooth by fixed orthodontics and endodontic treatment of 11 and 22 during orthodontic treatment. The second phase of treatment was to restore the smile by replacement of missing teeth with the help of fixed prosthodontics.

Fixed orthodontic appliance was used to extrude tooth 11, for that 0.022 in. standard edge wise brackets were bonded on 11, 13, 14, 22, 23, 24 and molar band with rectangular molar tube cemented on 16 and 26 which acted as anchor unit. Initial leveling and alignment was done with 014 in. AJ Wilcock wire. Subsequently stainless steel 018 in. and then 020-inch wire was ligated. The extrusion force on 11 was approximately 22-25 g [Figure - 9]. The whole procedure took around 2 months. After 2 months case was debonded and removable retainer was placed for a month.

Tooth 11 showed sign of pulpal degeneration during orthodontic treatment. Therefore, the pulp of tooth 11 was extirpated and canal was debrided and filled with gutta-percha.

Prosthodontic rehabilitation was done following orthodontic treatment. In such cases prosthodontic treatment is complicated and requires skill to form a definitive treatment plan. Porcelain fused to metal cantilever bridge was given for missing 12 with retainer on 13, as canines generally have long conical root and surrounded by dense compact bone. Twenty-one was replaced by 3-unit bridge with retainer on 11 and 22 and modified ridge lap pontic for missing 21 [Figure - 10].


   Discussion Top


The necessity for an interdisciplinary approach for the treatment of anterior tooth injury has been emphasized since a long time. It is also clear from these cases that without co-operation of each other the treatment of such cases is difficult.

It is advisable to give emergency treatment immediately after the injury to avoid the patient apprehension and the edema of soft tissue. If a patient is seen soon after the trauma and fracture is involving only enamel, the fractured edges can be covered with a commercial adhesive to protect the pulp from additional irritation.[9] If the fracture is long standing when first observed by the dentist and the pulp is vital and asymptomatic, protective covering is not required. If a patient with pulp exposure report to the Dentist after 72 h or more, the only treatment option available is pulpectomy, the complete removal of pulp.

The prognosis and survival of pulp depend on many variables, of which the duration for which pulp remains exposed in oral cavity and the stage of root formation is important. According to Finn intruded tooth is firmly driven in to the socket that can lead to pulpal death by severing the blood supply to the tooth. Thus, there are greater chances of cessation of root formation. While Skiller[10] has found that teeth with incomplete closure of root apices have more chances to retain their vitality due to better reparative capacity of the pulp.

In cases I and II as described earlier, patient reported long time after injury with intruded teeth and more then half of the coronal part fractured. Bracket placement is very difficult in such cases therefore we used removable appliance for orthodontic extrusion of teeth. Andreasen and Vestergaard[11] suggested that extrusion could be done by fixed or removable appliance although with removable appliance extrusion is slow as compared to fixed appliance. According to Evelyn K Mamber[12] major disadvantage of removable appliance is poor patient compliance and probably that is the primary reason for slow extrusion.

The restoration of fractured teeth after endodontic and orthodontic treatment depends upon amount of coronal tooth structure fractured. If only enamel and dentin is fractured than they can be restored by simple composite or by porcelain laminate. If more than half of the coronal part is missing then a dowel crown is required. If teeth are avulsed then situation becomes challenging, lateral incisor can be replaced by cantilever prosthesis on canine, as canine root is long and conical which is surrounded by dense cortical bone so it can bear extra-occlusal forces. In young patients it is important to save as many teeth as possible, both for psychological reason and for maintenance of function and esthetics. A definite treatment protocol should be followed to functionally and esthetically restore fractured anterior teeth.

Light orthodontic force either with the help of removable or fixed orthodontic appliance could be applied for the extrusion of intruded teeth.

 
   References Top

1.Gutmann JL, Marylou S, Gutmann E. Cause incidence & prevention of trauma to teeth. Dent Clin North Am 1995;39:1-13.  Back to cited text no. 1    
2.Harlamb SC, Messer HH. Endodontic management of a rare combination (intrusion & avulsion) of dental trauma. Endod Dent Traumatol 1997;3:42-6.  Back to cited text no. 2    
3.Andreasen JO. Etiology & pathogenesis of traumatic dental injuries: A clinical study of 1298 cases. Scand J Dent Res 1970:78;329-42.  Back to cited text no. 3    
4.Shpira J, Regev L, Liebfeld H. Re-eruption of completely intruded immature permanent incisors. Endod Dent Traumatol 1986:2;113-6.  Back to cited text no. 4    
5.Tronstad L, Trope M, Bank M, Barnett F. Surgical access for endodontic treatment of intruded teeth. Endod Dent Traumatol 1986;20:425-7.   Back to cited text no. 5    
6.Andreasen FM, Vestergaard PB. Prognosis of luxated permanent teeth the development of pulp necrosis. Endod Dent Traumatol 1985;1:207-20.  Back to cited text no. 6    
7.Bruszt P. Secondary eruption of teeth intruded into the maxilla by a blow. Oral Surg 1958;11:146-9.  Back to cited text no. 7    
8.Andresson L, Blomlof L, lindskog S, Feiolin B, Hammarstrom L. Tooth ankylosis - clinical radiographical and histological assessment. Int J Oral Surg 1984;13:423-31.  Back to cited text no. 8    
9. In : Sidney B, eds. Finn. Clinical pedodontics 4th Edn. WB Saunders Co: Philadelphia; p. 23.  Back to cited text no. 9    
10.Skieller V. The prognosis for young teeth loosened after mechanical injuries. Acta Odont Scand 1960;18:171-81.   Back to cited text no. 10    
11.Andreasen FM, Vestergaard PB. Prognosis of luxated permanent teeth - the development of pulp necrosis. Endod Dent Traumatol 1985;1:207-20.  Back to cited text no. 11    
12.Mamber EK. Treatment of intruded permanent incisors: a multidisciplinary approach. Endod Dent Traumatol 1994;10:98-104  Back to cited text no. 12    


Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]


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