Orthodontic treatment after intrusive dislocation and fracture of the maxillary central incisors

The treatment for intrusive dislocation is a clinical challenge and must be started soon after the intrusion injury. The affected tooth or teeth must be extruded by using light forces. This case report of traumatic intrusion of permanent central incisors aims to describe and discuss the process of repositioning the teeth in the dental arch. After a domestic accident, a 10-year-2-month-old boy suffered 11-mm intrusion of the maxillary central incisors along with enamel-dentin fracture and subluxation of the maxillary lateral incisors. Treatment started 2 days after the incident with an orthodontic extrusion of the maxillary central incisors with a fixed edgewise standard appliance. Orthodontic arches were used, and the force vectors were directed to the desired locations for the repositioning of the teeth. The treatment for extrusion and stabilization of the maxillary central incisors lasted 5 months and 22 days. Orthodontic traction with a fixed appliance is an effective procedure for the extrusion of both permanent maxillary central incisors intruded after trauma. Correct diagnosis, a short period between the trauma and the beginning of treatment, and appropriate mechanics were determining factors for a successful treatment.

Highlights

  • Intrusive luxation or intrusion of the teeth can result in complications.

  • Early orthodontic extrusion is a good option because it leads to better bone healing.

  • Starting treatment quickly after an injury contributes to a favorable outcome.

Intrusive luxation or intrusion results from dental trauma with an axial dislocation of the tooth into the alveolar bone. It is a severe traumatic dental injury because of the damage it causes to the gingival tissue, contusion of both the periodontal ligament and alveolar bone, and damage to the Hertwig’s epithelial root sheath when it happens during root development. It is an injury more common in deciduous dentition. The incidence in the permanent dentition is between 0.3% and 1.9%. These injuries can cause complications such as pulp necrosis, inflammatory root resorption, ankylosis, replacement resorption, and loss of marginal bone support. ,

Imaging examination (x-ray and tomography) allows observation as to whether there is a reduction of space for the periodontal ligament around the root, as the tooth lacks mobility ensuing trauma, and percussion can make a high, metallic (ankylotic) sound. Dental pulp tests generally offer negative results. Pulp revascularization is possible in immature and not partially developed teeth.

Intrusion is a traumatic injury most often related to the development of pulp necrosis in teeth with complete root formation. Therefore, the procedures for permanent and deciduous teeth differ significantly, as treatment options include spontaneous re-eruption, orthodontic extrusion, and surgical repositioning. The choice for the appropriate treatment relates to the stages of root formation. Spontaneous re-eruption is recommended for teeth with incomplete root formation, whereas orthodontic extrusion and surgical repositioning are principal options for teeth with complete root formation. In addition, immediate orthodontic extrusion expedites bone healing.

The pace of orthodontic extrusion must be in harmony with the healing process of the marginal bone, applying light and constant orthodontic forces (30 to 40 g of force). Pulp necrosis and inflammatory root resorption are the most frequent endodontic complications. Therefore, it is recommended that the root canal be treated with a temporary filling of calcium hydroxide to increase the longevity of the affected dental element. , Calcium hydroxide offers pulp necrosis favorable biologic healing properties. , ,

Complications are proportional to the amount of time elapsed between injury and intervention; therefore, dental treatment must ensue immediately after the trauma. , This period is crucial for therapeutics, as it directly impacts the prognosis. Finally, the unesthetic nature of severe incisor intrusion has psychological implications dictating immediate intervention.

This case report describes and discusses the treatment of severe traumatic intrusion of both maxillary central incisors.

Case report

A 10-year 2-month old boy in the mixed dentition stage suffered a domestic accident with a head injury while playing on the floor of his home. In the accident, the patient’s central incisors were intruded 11 mm, with enamel-dentin fracture and subluxation of the maxillary lateral incisors. The patient had good overall health without systemic alterations.

In the first clinical examination, the patient complained of pain in the affected region and presented alveolar mucosal swelling resulting from the injury. The fragments of the maxillary central incisors were lost in the accident, and only the palatal surfaces of these teeth were occlusally visible ( Fig 1 ). The apices of the maxillary central incisors were closed ( Fig 2 ).

Fig 1
Image of the area of the maxillary incisors after trauma. (A) Front view. (B) Occlusal view.

Fig 2
Periapical radiographs of the area of the maxillary incisors after trauma. (A) Lateral right incisor; (B) central incisors; (C) lateral left incisor.

The treatment proposal was immediate orthodontic traction with a fixed appliance bonded to the permanent maxillary teeth. The lateral incisors were not initially used as anchorage units as they were mobile after the injury. A passive arch was made with a 0.0215 × 0.028-in stainless-steel wire supported by the maxillary permanent first molars and first premolars. The orthodontic traction started with elastic chains (with 30-40 g of force) linking the retention wire bends on the region of the central incisors to the buttons bonded to the palatal surfaces of the maxillary central incisors ( Fig 3 ). Weekly examinations were performed at the early stage of treatment to verify if the intruded teeth were ankylosed.

Fig 3
Intrabuccal images on the initial stage of treatment with steel edgewise standard brackets bonded to the permanent maxillary teeth and buttons on the palatal surfaces of the maxillary central incisors. Passive 0.0215 × 0.028-in gauge stainless-steel wire on the posterior teeth and chain elastics with light forces to extrude the maxillary central incisors. (A) Right lateral view; (B) front view; (C) left lateral view; ( D ) occlusal view.

As the teeth were extruded, new 0.0215 × 0.028-in stainless-steel archwires were made according to the need for force direction for the teeth to reach their normal positions ( Fig 4 ). Because part of the labial surfaces of the maxillary central incisors was exposed, brackets were bonded to assist the extrusion, and a cone-beam computed tomography (CBCT) scan was done to evaluate both the root and bone surfaces of the affected area ( Fig 5 ).

Fig 4
(A) Second archwire. (B) Image after 19 days of treatment.

Oct 30, 2021 | Posted by in Orthodontics | Comments Off on Orthodontic treatment after intrusive dislocation and fracture of the maxillary central incisors
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