Dr HV Shanmugam Senior Lecturer Department of Pedodontics and Preventive Dentistry Sree Balaji Dental College and Hospital Pallikaranai, Chennai India Email: firstname.lastname@example.org
Intrusive luxation is the most common trauma during early infancy which results in the displacement of the tooth into its alveolus. Depending on the severity of the intrusion, the American Academy of Pediatric Dentistry recommends either extraction or spontaneous re-eruption for the primary tooth. This case report provides a brief insight into surgical repositioning as an alternative treatment option for the management of intruded primary tooth in a 4-year-old girl.
In children, orofacial trauma can result in fracture, displacement or trauma of teeth. These factors can generate significant negative effects on the psychological, aesthetic and functional aspects of development.1 The greatest incidences of trauma to the primary dentition occur at 2–3 years of age when motor coordination is underdeveloped while children are learning to walk.2
Intrusion injuries commonly occur in the primary dentition and account for 4% to 22% of damage to anterior primary teeth.3–12 These injuries are more frequent in 1–3 year olds because of the high resilience and flexibility of the supporting structures around the primary teeth.13
Intrusion is defined as luxation injury resulting from an axially directed impact which drives the tooth deeper into the alveolar socket and damages the periodontal ligament and neurovascular bundle fibres. Depending on the magnitude of the impact, the injury can be divided into three types: Type I, less than 50% of the crown is intruded; Type II, more than 50% of the crown is intruded; and Type III, the entire crown is intruded.14
Due to the anatomic proximity between the roots of the primary teeth and their permanent successors, trauma to the primary dentition may cause developmental disturbances in succedaneous teeth. Therefore, in addition to rendering treatment to the intruded primary teeth, the dentist must also be aware of the possibility of injury to the developing permanent teeth.4
The American Academy of Pediatric Dentistry (AAPD) recommendation for managing the intruded primary incisors is either extraction or waiting for spontaneous re-eruption, depending on the severity of intrusion. This case report highlights how we treated intrusion with surgical repositioning as a successful treatment option.
A 4-year-old girl presented to the Department of Pedodontics and Preventive Dentistry, Dental College and Hospital with the chief complaint of a broken left upper front tooth. History revealed that the patient had a fall while playing. Further questions to rule out child abuse were asked. Tetanus toxoid was administered as a prophylactic measure.
The patient’s general health was normal and the neurological status was unaffected. On extraoral examination, there was neither a head injury nor nasal bleeding. The intraoral clinical examination showed laceration of the lower lip, intrusion of the maxillary left central incisor (61) and subluxation of the left lateral incisor (62) (Fig 1). The tooth apex was displaced labially and the crown lingually in 61 (Fig 2). Radiographic findings confirmed the same and the obliteration of periodontal ligament space was seen in 61 (Fig 2). Interestingly, a mesiodens was also found between 51 and 61.
As the patient was very cooperative, the treatment was done under local anaesthesia. Soft tissue lacerations were cleaned; the wound debrided and sutures were placed with 3-0 black braided silk (Ethicon, Johnson & Johnson Ltd). The incisor was surgically repositioned with forceps as suggested by Soporowski et al.15 (Fig 3). During the procedure, extreme care was taken to avoid any damage to the soft tissues and underlying successor. After surgical repositioning, the position was confirmed with an intraoral periapical radiograph (IOPA). The tooth was splinted with rectangular stainless steel wire and composite (Fig 4). The subluxated 62 was also included in the splint. Immediately after splinting, an access cavity was prepared and pulp tissue was removed to avoid pulpal necrosis. Calcium hydroxide (RC Cal, Primedent) dressing was given and access was closed with IRM (Dentsply).
The parents were advised to clean the affected area with chlorhexidine mouthwash using a cotton swab twice a day. The patient was placed on a soft diet. Two weeks later, an IOPA radiograph was taken followed by the removal of the splint. The upper-left central incisor was found to be in occlusion. After three weeks, pulpectomy was completed with Metapex (Meta Dental Corporation) in 61 and access was sealed with glass-ionomer cement.
Subsequently, the patient was reviewed over the next 18 months. Clinical and radiographic examination (Figs 5–6) were undertaken periodically (at 1 month, 3 months, 6 months, 9 months, 12 months, 18 months and 20 months) to rule out any mobility, ankylosis, and periapical pathosis in 61 and 62. The gingival pocket level was compared with the contralateral tooth by William’s probe and was found to be normal. During the follow-up, a very mild discolouration was noted in 61. As it was not significantly visible, no aesthetic management was carried out. The patient is still under observation, even though the parents were very pleased with the final outcome.
As preschool-age children lack the neuromuscular coordination to perform precise and safe movements, they are more susceptible to falls and other injuries. In contrast to hard tissue injuries that are more commonly seen in the permanent dentition, luxation injuries predominate in the primary dentition.16,17 This is due to the high elasticity of the alveolar bone and large bone marrow space surrounding the primary teeth.4
According to the literature, one of the major factors to influence the choice and success of treatment is the time between the trauma and treatment onset.18 In a study of 73 patients with traumatic injuries in the primary dentition, Onetto et al.11 stated that most of the patients reported to the dental clinic only after 24 hours. Therefore, time has a decisive effect on treatment outcome. In this case, the patient reported to the department within an hour. This was one of the key reasons for the success of our treatment. Cunha et al. also acknowledged this aspect in their case report.19
The most commonly recommended treatment for intrusion in primary teeth is to allow the intruded tooth to re-erupt, provided it is positioned labially away from the developing permanent tooth bud.16 Based on the literature, the average time for the spontaneous re-eruption is 3 months.16,18,20–27 During this period, endodontic intervention is virtually impossible. Andreason documented that pulp necrosis is highly associated with moderate or severe intrusion (Type II and Type III). Disintegration of pulpal tissue might result in inflammation of periapical tissue.3 Long-term acute infection becomes a chronic abscess, which can generate purulent exudate in the periapical region and might contribute to hypoplasia of the permanent teeth.3 A cephalometric study has shown that the hard tissue barrier between the primary incisor and its permanent successor has a thickness of less than 3 mm,28 and this barrier might merely consist of connective tissue and fibrous tissue.18 Experimental studies in monkeys have revealed that periapical inflammation of more than 6 weeks around primary incisors did lead to a developmental alteration in the permanent teeth.29
According to a study by Diab and Elbadrawy, 20% to 22% of intruded primary incisors did not re-erupt fully, or in perfect alignment, or failed to re-erupt.3 During spontaneous re-eruption, incursion of bacteria through the gingival sulcus may incite gingival redness, swelling, spontaneous bleeding and pain.3 Therefore, surgical repositioning was opted rather than spontaneous re-eruption and extraction. Saporowski et al.15 also proposed this technique for intruded primary teeth. Furthermore, this treatment plan avoids the alteration in occlusion as well as aesthetic problems.
Andreason acknowledged the high frequency of pulp necrosis in 4–6 year olds when compared to 2–3 year olds, as the narrow apex and the non-resiliency of alveolar structures will lead to necrosis.16 The injured pulpal tissue of the intruded tooth may result in a sequel of events, such as pulp necrosis, internal or external root resorption, ankylosis and obliteration of the pulp canal.3,14,16,30 This has been reported as common sequels ranging from 14%3 to 53%30 of the intruded cases. These unwanted sequels were avoided by means of immediate pulpectomy, followed by placing calcium hydroxide as an intracanal medicament.
Additionally, severe injury to the periodontal ligament during intrusion may lead to ankylosis of the primary incisor and delayed or ectopic eruption of its permanent successor. In this case, the treatment option of surgical repositioning, immediate removal of pulp tissue, calcium hydroxide dressing and maintenance of good oral health by means of chlorhexidine mouthwash permitted favourable periodontal healing and avoided unwanted sequel-like ankylosis.
Although most problems associated with the intruded primary incisor have been avoided with this management, the patient is still under observation to rule out any sequelae in the successor.
The significant compliance from both patient and parents made this particular treatment possible and resulted in a good outcome. Otherwise, ‘waiting for spontaneous eruption’ would have been the simple option in these circumstances.
This case report provides a different option for the management of intruded primary teeth. Surgical repositioning can be used as a successful treatment option. However, long-term follow-up studies should be undertaken to confirm the success of this type of treatment in primary teeth.