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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 REPORT
Year : 2008  |  Volume : 26  |  Issue : 6  |  Page : 82-85
 

Surgical repositioning of intruded immature permanent incisor: An updated treatment concept


Department of Pedodontics and Preventive Dentistry, M.M.College of Dental Sciences & Research, Mullana. Ambala, Haryana, India

Correspondence Address:
S Garg
Prof. of Pedodontics, M M Dental college, Mullana, Ambala
India
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Source of Support: None, Conflict of Interest: None


PMID: 19075455

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   Abstract 

Intrusion of immature permanent anterior teeth presents a great dilemma due to variety of treatment options. The ideal treatment option is the one with least probability of developing complications like external root resorption, obliteration of pulp canal, marginal bone loss etc. This paper presents a case report with treatment strategy of repositioning, splinting, successfully attempted apexification and obturation of a completely intruded immature permanent central incisor. Excellent healing with no post-operative complications even after 10 months of follow up.


Keywords: Complete intrusion, immature, surgical repositioning, root resorption


How to cite this article:
Garg S, Bhushan B, Singla S, Gupta K P. Surgical repositioning of intruded immature permanent incisor: An updated treatment concept. J Indian Soc Pedod Prev Dent 2008;26, Suppl S2:82-5

How to cite this URL:
Garg S, Bhushan B, Singla S, Gupta K P. Surgical repositioning of intruded immature permanent incisor: An updated treatment concept. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2021 Apr 19];26, Suppl S2:82-5. Available from: https://www.jisppd.com/text.asp?2008/26/6/82/43539



   Introduction Top


Intrusion is apical displacement of the tooth into the alveolar bone, a rare injury seen to represent only 0.3-2% of traumas affecting the permanent dentition. [1] The damage caused to the hard and soft tissues (i.e. gingival tissues, periodontal ligament (PDL), alveolar bone and pulp) in these injuries arises a multitude of complications including loss of gingival attachment, marginal bone loss (MA) and root resorption (RR). Furthermore, pulpal necrosis (PN) and failure of root formation are frequent in cases of injury to immature teeth. [1] These reasons associated with poor post-treatment outcomes have made the management of intrusive luxations a controversial topic. Historically, suggested treatment methods include- Spontaneous re-eruption, immediate surgical repositioning and fixation, orthodontic repositioning and a combination of surgical and orthodontic therapy. [2] There is no single agreed-on-approach to treatment. [3] For a completely intruded immature tooth immediate surgical repositioning has been documented as the treatment of choice. [2],[4],[5] In the present case surgical management of completely intruded immature permanent incisor is discussed yielding successful treatment outcomes with no postoperative complication.


   Case Report Top


A 10 year old boy reported to Pediatric Dentistry Clinic with a history of fall 4 days back, injured his maxillary incisors and complained of missing permanent maxillary right central incisor [Figure 1]. The medical history was non contributory.

Intraoral examination revealed missing permanent maxillary right central incisor, crown fracture of left maxillary central incisor involving enamel and dentin and subluxation of right lateral incisor.

Radiographic examination revealed a completely intruded right permanent maxillary central incisor apical to the interdental bone with its midroot at the level of apex of adjacent central incisor. Both central incisors had immature root apex with parallel canal walls [Figure 2] and periodontal space around the intruded tooth had diminished, but no root fractures could be detected.

Immediate surgical repositioning of the intruded permanent central incisor was considered under local anaesthesia. Tooth was located and flap raised to expose the crown of underlying intruded central incisor [Figure 3] following which tooth was gently and carefully luxated with dental forceps and brought back into the desired position.

After repositioning to normal occlusion, tooth was stabilized and splinted with a 0.9mm stainless steel wire and light cure composite resin with adjacent teeth [Figure 4].

Splinting was removed after 14 days [Figure 5] and endodontic therapy initiated on both the central incisors.

An attempt of apexification was made by placing calcium hydroxide as intracanal medicament. [18] Pure calcium hydroxide powder was mixed with normal saline (0.9%w/v) to achieve consistency to form a 1cm string. The material was then filled in the canal with the help of lentulo spiral and condensed with paper points with patient in a chin up position [Figure 6]. The access cavity was sealed with zinc oxide eugenol cement and IRM. The patient was put on regular radiographic follow up.

It was at 3 rd month recall visit that an apical end closure was evident clinically and radiographically in both the incisors [Figure 7].

Root canals were obturated with gutta percha points and light cure composite build up performed to restore the aesthetics of the patient [Figure 8].

At 6 month recall visit, clinical examination revealed no periapical pathology, subluxated lateral incisor had normal periodontal contour, was positive to the vitality test with no mobility. On radiographic examination, healing was evident without signs of root resorption or any other reported post treatment complication with normal periodontal space around the intruded tooth being maintained [Figure 9].


   Discussion Top


Intrusive luxations are serious injuries with high risk of complicated sequelae. This risk is increased manifold when the tooth is completely intruded into the alveolar socket with an immature root apex. This case report presents a case involving right permanent maxillary central incisor.

Historically, suggested treatment methods of intruded teeth have been- spontaneous re-eruption, immediate surgical repositioning and fixation, orthodontic repositioning and a combination of surgical and orthodontic repositioning. [2] The term spontaneous eruption gives a false optimistic impression, as tooth movement after injury is unpredictable and pathological rather than developmental. Another imprecise term is orthodontic repositioning as the traction forces used to move intruded incisors exceed those of conventional orthodontic treatment and completely intruded teeth do not have a functional PDL, a prerequisite for orthodontic movement. Current management strategies include- surgical reduction ( immediate repositioning ), repositioning with traction ( active repositioning ) and waiting for the tooth to return to its preinjury position ( passive repositioning ). [3] Recently immediate surgical repositioning has been documented as the treatment of choice for completely intruded teeth. [8],[9]

A study of 29 intruded permanent teeth by Kinirons and Sutcliffe failed to show that surgical repositioning increased prevalence of resorption. In their study on factors affecting resorption of intruded permanent incisors authors concluded that there is no additional risk of resorption if severely intruded incisors are repositioned surgically. Another significant finding was that the intruded teeth with closed apices have increased chances of root resorption compared to immature teeth thus favouring immediate surgical repositioning in completely intruded immature teeth. [7]

In the present case, permanent maxillary incisor was completely intruded into the alveolar bone and was embedded with root surface in intimate relationship with bone and thus high chances of ankylosis and root resorption were anticipated. [10] Aim of the treatment here is to restore the tooth in its original position by decompressing the injured tissue and re-establishing normal relationship between tooth and bone. Thus passive repositioning was not considered as the treatment option. Orthodontic repositioning was not considered as placing brackets on the intruded tooth was not feasible with various disadvantages accompanied with this method. It is time consuming with a long retention period, making patient's co-operation a critical factor. Immediate surgical repositioning was opted as the treatment of choice as it extrudes and saves the tooth in one step procedure. [11],[12] It is simpler and less time-consuming than orthodontic repositioning. [13] Immature root apex favoured treatment plan [14] and pathological complications like root resorption, periapical destruction, ankylosis and marginal bone loss were not noticed in present case after a follow up of 10 months of surgical and endodontic treatment of the intruded incisor. It has been established that appropriate and timely removal of necrotic pulp followed by conventional root canal treatment will prevent inflammatory replacement resorption whereas failure to remove necrotic pulp stimulates it. [15] Calcium hydroxide arrests inflammatory response with a high degree of success by making osteoclastic activity impossible and stimulating repair process of tissue. [12],[16] Thus, endodontic treatment was accomplished with calcium hydroxide therapy as soon as tooth responded negatively to the pulp vitality tests. [19]

In conclusion, surgical repositioning and root canal treatment using calcium hydroxide were successful in repairing the potential damage caused by the impact of an intrusive injury and successful prevention of any post-operative complication commonly associated with these injuries. Thus immediate surgical repositioning can be suggested as a successful treatment of choice for completely intruded immature permanent incisors.

 
   References Top

1.Andreasen JO, Andreasen FM, Bakland LK. 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;22:90-98.  Back to cited text no. 1    
2.Jang KT, Kim JW, Lee SH, Kim CC, Godoy FG. Reposition of intruded permanent incisor by a combination of surgical and orthodontic approach: a case report. J Clin Pediatr Dent 2002;26(4):341-6.   Back to cited text no. 2    
3.Faria G, Silva RAB, Fiori MJ, Filho NP. Re-eruption of traumatically intruded mature permanent incisor: case report. Dent Traumatol 2004;20: 229-32.  Back to cited text no. 3    
4.Caliskan MK, Gomel M, Turkun M. Surgical extrusion of intruded immature permanent incisors. Oral Surg Oral Med Oral Pathol 1998;86:461-4.  Back to cited text no. 4    
5.Ebeleseder KA, Santler G, Glockner K, Hulla H. An analysis of 58 traumatically intruded and surgically extruded permanent teeth. Dent Traumatol 2000;16:34-9.  Back to cited text no. 5    
6.Filho P, Faria G, Assed S, Pardini LC. Surgical repositioning of traumatically intruded permanent incisor: case report with a 10year follow up. Dent Traumatol 2006; 22:221-25.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.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. 7    
8.Gungor HC, Cengiz SB, Altay N. Immediate surgical repositioning following intrusive luxation: a case report and review of the literature. Dent Traumatol 2006; 22:340-44.   Back to cited text no. 8    
9.Andreasen JO, Andreasen FM, Bakland LK. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect 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. 9    
10.Al-Badri S, Kinirons M, Cole BOI, Welbury RR. Factors affecting resorption in traumatically intruded permanent incisors in children. Dent Traumatol 2002; 18:73-76.   Back to cited text no. 10    
11.Kinirons MJ. Treatment of traumatically intruded permanent incisor teeth in children, UK National Clinical Guidelines in Paediatric Dentistry. Int J Paediatr Dent 1998;8:165-8.  Back to cited text no. 11    
12.Caliskan MK. Surgical extrusion of a completely intruded permanent incisor. J Endod 1998;24(5),381-4.  Back to cited text no. 12    
13.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 Sep-Oct;26(5):421-5.  Back to cited text no. 13    
14.Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions. Dent Traumatol 2003; 19:266-73.   Back to cited text no. 14    
15.Andreasen JO. Injuries to developing teeth. In: Andreasen JO, Andreasen FM, editors. Textbook and color atlas of traumatic injuries to the teeth, 3rd edn. Copenhagen: Munksgaard; 1994.  Back to cited text no. 15    
16.Kenny DJ, Barrett EJ, Casas MJ. Avulsions and Intrusions; the controversial displacement injuries. J Can Dent Assoc 2003; 69: 308-13.   Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Roberts J, Olsen C, Messer H. Conservative management of an intruded immature maxillary permanent central incisor with healing complication of pulp bone. Aust Endod J. 2001 Apr;27(1):29-32.  Back to cited text no. 17    
18.Camoes IC, Salles MR, Chevitarese O. Ca2+ diffusion through dentin of Ca(OH)2 associated with seven different vehicles. J Endod 2003;29(12):822-25.  Back to cited text no. 18    
19.Jung IY, Lee SJ, Hargreaves KM. Biologically based treatment of immature permanent teeth with pulp necrosis: A case series. J Endod 2008;34(7):876-87.  Back to cited text no. 19    


    Figures

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


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    Abstract
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