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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 46-50

Management of Dentoalveolar Trauma in Late Mixed Dentition


1 Department of Pediatric and Preventive Dentistry, DY Patil University School of Dentistry, Navi Mumbai, Mumbai, Maharashtra, India
2 Department of Paediatric and Preventive Dentistry, Y.M.T. Dental College and Research Institute, Navi Mumbai, Mumbai, Maharashtra, India

Date of Web Publication27-Jun-2016

Correspondence Address:
Rupinder V Bhatia
Department of Pediatric and Preventive Dentistry, D.Y. Patil University School of Dentistry, Nerul, Navi Mumbai - 400 706, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2393-8692.184739

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  Abstract 

Dentoalveolar trauma leading to intrusion and lateral luxation of maxillary lateral and central permanent incisor in late mixed dentition phase is reported. The laterally luxated central incisor tooth was splinted for 3 weeks. Endodontic treatment of the same with intracanal calcium hydroxide dressing and subsequent obturation with gutta-percha was accomplished after splint removal. The intruded lateral incisor was kept under observation to allow spontaneous re-eruption. Clinical and radiographic follow-up to 9 months revealed satisfactory periodontal healing of the repositioned maxillary central incisor and passive re-eruption of intruded lateral incisor. The central incisor was esthetically restored and mouthgaurd was fabricated to prevent future injuries to the dentition.

Keywords: Dentoalveolar trauma, intrusion, luxation, mouthgaurds, splinting


How to cite this article:
Bhatia RV, Jawdekar A, Mathrawala NR. Management of Dentoalveolar Trauma in Late Mixed Dentition. Indian J Oral Health Res 2016;2:46-50

How to cite this URL:
Bhatia RV, Jawdekar A, Mathrawala NR. Management of Dentoalveolar Trauma in Late Mixed Dentition. Indian J Oral Health Res [serial online] 2016 [cited 2019 Dec 8];2:46-50. Available from: http://www.ijohr.org/text.asp?2016/2/1/46/184739


  Introduction Top


Dental trauma is a common injury, especially in children. In permanent dentition, a high incidence of traumatic injuries is seen for boys aged 8-10 years, probably related to more vigorous play characteristic of this age group. [1],[2] The majority of dental injuries in permanent dentition involve the anterior region of maxilla, of which luxation injuries comprise 15-61% of the dental traumas that include lateral, intrusive, and extrusive luxation injuries. [1] The most commonly involved tooth is the maxillary central incisor followed by lateral incisor. Intrusion injury has a rarer occurrence in permanent dentition when compared with other types of luxation injuries. It comprises 3% of traumatic injuries in the permanent dentition. [3] The primary etiological factors are bicycle accidents, sports injury, falls, and fights. [1] Multiple injuries in the form of lateral luxation and intrusion although less common than single tooth injuries are seen in case of accidental and sport-related trauma.

Traumatic luxation is a type of injury that involves eccentric displacement of the tooth, accompanied by communication or fracture of alveolar socket. The accepted treatment for lateral luxation is repositioning of the tooth at the earliest and stabilization with a splint up to 3 weeks. [1],[4] For intrusion, it is recommended to wait for spontaneous re-eruption. [1],[3],[5] The greatest frequency (64%) [1] of pulp necrosis is encountered among intrusions followed by lateral luxation and extrusion, more frequently in teeth with fully developed roots. A thorough follow-up period can disclose a number of complications such as pulp canal obliteration, pulp necrosis, inflammatory root resorption, and loss of marginal bone support. [1],[3],[5],[6]

In terms of prevention of dentoalveolar injuries, the widespread use of mouthgaurd is an important measure in contact sports. [7] Thus, judicious use of diagnostic aids such as radiography and vitality testing and prompt surgical and endodontic intervention, with sufficient follow-up are keys to the successful management of dentoalveolar fracture.

This paper reports the management of dentoalveolar trauma involving lateral and intrusive luxation in incisor teeth in mixed dentition period with stabilization, endodontic therapy, reestablishment of function and esthetics as well as prevention through fabrication of mouthguard and follow-up.


  Case report Top


A 12-year-old male child presented to the Department of Pediatric and Preventive Dentistry with traumatized upper front teeth and bleeding from mouth as a result of a direct, unintentional impact while swimming. The patient was brought to the clinic a day after injury where he received immediate attention. The child was conscious; there was no evidence of bleeding from nose and ears, with no episode of vomiting/convulsion, suggestive of any central nervous system injury. The child revealed a history of rheumatic heart disease 5 years back. The immunization status of the child was satisfactory. The child had been administered injection tetanus toxoid and advised antibiotics and analgesics by a general physician.

On clinical examination, laceration of the upper lip, alveolar mucosa, and palatal mucosa was noticed. The maxillary left central incisor was fractured at the incisal third of the crown and luxated buccally. The maxillary right central incisor was also fractured at the incisal third of the crown. Both teeth showed mobility. The maxillary left lateral incisor appeared intruded due to trauma [Figure 1] and [Figure 2]. The dental age of the child was approximately 10-11 years, indicative of late mixed dentition stage.
Figure 1: Preoperative photograph showing 21 displaced buccally, 22 intruded, and fracture involving enamel and dentin of 11 and 21 (facial view)

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Figure 2: Preoperative photograph showing 21 displaced buccally, 22 intruded, and fracture involving enamel and dentin of 11 and 21 (palatal view)

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On the day of the examination, a treatment plan was presented to the parents that included soft tissue care, splinting of mobile teeth, commencement of endodontic treatment, and watchful supervision for the eruption of maxillary lateral incisor on the left side. The soft tissues were cleaned with irrigation using diluted betadine and saline. The patient was advised ice application on the upper lip intermittently to prevent soft tissue edema. An intraoral periapical (IOPA) radiograph was obtained [Figure 3]. The child was advised to complete blood investigations as a routine preparation for surgery. A pediatrician's opinion and consent was sought in view of rheumatic heart disease and antibiotic cover before the commencement of the dental treatment.
Figure 3: Intraoral periapical radiograph showing widening of periodontal ligament space in relation to 21 and intrusion of 22

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Within 24 h, the child was taken for surgery. The child was administered bilateral infraorbital blocks. Blood clots were debrided by irrigation with normal saline. The maxillary left central incisor was relocated with gentle digital pressure and then, a composite wire splint extending from the maxillary left central incisor to the maxillary right first premolar was placed to keep luxated teeth in position [Figure 4]. Sutures were given to approximate the labial and palatal mucosa [Figure 4]. The child was instructed to have soft diet, gentle brushing, and thorough rinsing with betadine mouthwash and continue amoxicillin 500 mg tid for 5 days and ibuprofen 200 mg qid SOS. The splint was maintained for 15 days and then removed with care [Figure 5]. A necrosed bony sequestrum present between the left and right central incisors was removed under local anesthesia following the removal of splint [Figure 6].
Figure 4: Photograph showing immobilization with wire composite splint extending from 21 to 14 and sutures in place

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Figure 5: Photograph showing the presence of bony sequestrum between 11 and 21

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Figure 6: Photograph after the removal of splint (2 weeks postoperative)

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Endodontic treatment was started for the maxillary left central incisor on the same day of splinting to prevent surface resorption, and IOPA radiograph exhibited apical widening of periodontal ligament (PDL) space. After obtaining access palatally, the pulp was extirpated, and the root canal was filled with calcium hydroxide. In the following visits, instrumentation of the canal followed by obturation of the tooth with gutta-percha was done [Figure 7]. The fractured left and right central incisors were then restored with composite under rubber dam isolation [Figure 8]. The left lateral incisor was kept under observation.
Figure 7: Intraoral periapical radiograph showing completed endodontic treatment of 21

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Figure 8: Intraoral photograph showing esthetic restoration of 11 and 21

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Follow-up radiographs were taken after 1 month and every 3 monthly for a period of 9 months [Figure 9]. The teeth 11, 21, and 22 were kept under close observation. Follow-up radiographs up to 9 months show radiographic evidence of healing. Teeth 22 that appeared to have intruded showed marked coronal movement and now appears stable since 3 months in the present location with maintained vitality [Figure 10]. The child was counseled regarding the prevention of dentofacial injuries, and a custom mouthgaurd made of thermoplastic polyvinyl resin was fabricated for wearing during contact sports activities [Figure 11].
Figure 9: Intraoral periapical radiographs 3 months, 6 months, and 9 months postoperative

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Figure 10: Photograph showing passive eruption in stable occlusion of intruded 22 after 9 months

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Figure 11: Intraoral photograph of custom mouthgaurd in place

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  Discussion Top


The accepted treatment for luxation injury is immediate repositioning of the extruded tooth and stabilization, if necessary. [1] The most important factor in determining the treatment plan for luxated teeth is the presence or absence of significant apical displacement at the time of injury. [6] If there is radiographic evidence that the apex has moved out of its normal position, then there is a very high probability of compression of apical neurovascular bundle. Consequently, the tooth is likely to require root canal therapy, irrespective of whether it is mature or immature. Electric pulp testing of mechanically loosened teeth immediately after injury is not a reliable criterion for assessing vitality. [2] According to Andreason, the factor of the time interval from injury to repositioning of displaced teeth appears critical causing root surface resorption. [1] Teeth treated within 90 min after injury show a very low frequency of root resorption compared with teeth treated at a later time. Since the child reported to us only after 24 h, as the risk of pulp necrosis increases with the extent of injury to the pulp and PDL and in teeth with complete root formation, prophylactic extirpation of the pulp has been recommended to prevent inflammatory root resorption. [1],[3] Dressing of the root canal with calcium hydroxide has been shown to give a high frequency of healing. [5] In the present case, endodontic therapy was started early, followed by calcium hydroxide dressings to promote healing of periodontal tissues for 2 weeks. The conventional endodontic treatment was completed with a postendodontic composite restoration in 2-3 weeks after splint removal. The healing after endodontic treatment has been satisfactory both clinically and radiographically.

In the present case, IOPA radiograph showed widening in the apical third for the left maxillary central incisor, and lateral luxation with apical displacement usually shows a PDL space that has "empty" radiolucent space apically. [6]

Although there is no consensus reached on the optimal treatment of intruded permanent teeth in literature, [1] the options include allowing spontaneous re-eruption of the tooth, immediate surgical repositioning and fixation, and orthodontic repositioning. [3] It is recommended to wait for re-eruption up to 3 weeks for immature teeth because of their high potential for eruption. [8] Furthermore, although such teeth often require endodontic treatment, [3] in the reported case here, we did not treat the tooth pulpally since the tooth has been vital till date.

Semi-rigid splinting is commonly used to maintain the proper anatomical position of the tooth and prevent further trauma. [1],[2],[6] This splinting technique allows physiological tooth movement, preventing points of ankylosis from becoming permanent. Splinting is recommended for all loosened or displaced teeth, but in the case of intrusion, a period of careful observation is recommended to allow spontaneous re-eruption to take place. [2],[8] The maxillary left lateral incisor that showed incomplete root apex formation was not included in the splinting to allow spontaneous re-eruption. The splinting included teeth as follows: 21, 11, 12, and 14.

It is important in all cases of luxation of teeth that assessment must be undertaken at 6 monthly intervals for at least 2 years following the removal of splint or on re-eruption of the teeth following intrusion. [1],[8] Follow-up of 9 months has been reported in the present case. Periodic vitality testing and radiographs have been carried out.

Currently, there are three main types of mouthgaurds available to athletes. These are stock, mouth-formed (i.e., boil and bite) and custom-fabricated mouthgaurds. [2],[9] Custom-made mouthgaurds offer advantages of optimal adaptation, maximum retention, superior comfort, and minimal interference with both breathing and speech. [9],[10] The patient was of an athletic personality, constantly at a risk for trauma. The child was counseled regarding the prevention of sports injuries. In addition, a custom-made mouthgaurd was fabricated to protect the patient from future dentoalveolar injury.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andreasen FM, Andreasen JO. Luxation injuries. In: Andreasen JO, Andreasen FM, editors. Textbook and Colour Atlas of Traumatic Injuries to the Teeth. 3 rd ed. Copenhagen: Munksgaard Publishers; 1994.  Back to cited text no. 1
    
2.
Finn SB, Ripa L. The care of injuries to anterior teeth of children. In: Finn S, editors. Textbook of Clinical Pedodontics. 4 th ed. Philadelphia: W.B. Saunders; 1991.  Back to cited text no. 2
    
3.
Güngör HC, Cengiz SB, Altay N. Immediate surgical repositioning following intrusive luxation: A case report and review of the literature. Dent Traumatol 2006;22:340-4.  Back to cited text no. 3
    
4.
Martins WD, Westphalen VP, Perin CP, Da Silva Neto UX, Westphalen FH. Treatment of extrusive luxation by intentional replantation. Int J Paediatr Dent 2007;17:134-8.  Back to cited text no. 4
    
5.
de Alencar AH, Lustosa-Pereira A, de Sousa HA, Figueiredo JH. Intrusive luxation: A case report. Dent Traumatol 2007;23:307-12.  Back to cited text no. 5
    
6.
Berman LH, Blanco L, Cohen S, editors. Luxation injuries. In: A Clinical Guide to Dental Traumatology.  St. Louis: Elsevier Health Sciences; 2006.  Back to cited text no. 6
    
7.
Santos Filho PC, Quagliatto PS, Simamoto PC Jr., Soares CJ. Dental trauma: Restorative procedures using composite resin and mouthguards for prevention. J Contemp Dent Pract 2007;8:89-95.  Back to cited text no. 7
    
8.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007;23:66-71.  Back to cited text no. 8
    
9.
Del Rossi G, Leyte-Vidal MA. Fabricating a better mouthguard. Part I: Factors influencing mouthguard thinning. Dent Traumatol 2007;23:149-54.  Back to cited text no. 9
    
10.
Mathewson RJ, Primosch CR, editors. Trauma to anterior teeth. In: Textbook of Fundamentals of Pediatric and Preventive Dentistry. 3 rd ed. Chicago: Quintessence Pub. Co.; 1995.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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