Year : 2007 | Volume
: 25 | Issue : 5 | Page : 13--16
Management of traumatically intruded permanent incisors
MH Shivayogi, LS Anand, DS Dayanand
Department of Pedodontics and Preventive Dentistry, KLES's Institute of Dental Sciences, Belgaum - 590 010, Karnataka, India
M H Shivayogi
Department of Pedodontics and Preventive Dentistry, K.L.E.S«SQ»s Institute of Dental Sciences, Nehru Nagar, Belgaum - 590 010, Karnataka
Intrusive luxation of permanent teeth has great psychologic impact on both parents and children and presents clinical challenge for the dentist, all the more due to severe complications it is difficult to manage this group of dental injuries. This paper describes the management of traumatically intruded permanent maxillary-central incisor in an 11-year-old girl. After 12-month follow-up, it was seen that teeth were fully re-erupted and are in functional alignment with other teeth.
|How to cite this article:|
Shivayogi M H, Anand L S, Dayanand D S. Management of traumatically intruded permanent incisors.J Indian Soc Pedod Prev Dent 2007;25:13-16
|How to cite this URL:|
Shivayogi M H, Anand L S, Dayanand D S. Management of traumatically intruded permanent incisors. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2022 Nov 27 ];25:13-16
Available from: http://www.jisppd.com/text.asp?2007/25/5/13/34740
Intrusive luxation is a common type of dental injury in the primary dentition; however it occurs less frequently in permanent dentition. Intrusive luxation of permanent teeth has great psychologic impact on both parents and children and presents clinical challenge for the dentist. 
Intrusive luxation is defined as "the apical displacement of tooth into the alveolar bone, the tooth is driven into the socket, compressing periodontal ligament and commonly causes a crushing fracture of the alveolar socket".  Intruded teeth are classified according to the degree of clinical displacement into three types i.e., mildly intruded (6 mm). 
Clinically the intruded teeth may appear shortened with bleeding from the gingiva. Most of the intruded teeth are not sensitive to percussion and are completely firm. Percussion test often elicits a high-pitched metallic sound, similar to an ankylosed tooth. , The various complications associated with such type of injury are pulp necrosis, external / internal root resorption, loss of marginal bone support, replacement resorption / ankylosis, disturbance in continued root development, partial / total pulp canal obliteration and gingival recession. 
Treatment will vary according to the child's ability to cooperate, the child's medical history, the severity of intrusion and whether the intruded tooth has a mature or immature root [Table 1]. 
There are three treatment modalities to manage intrusive luxation: 
Observation for spontaneous re-eruption.Immediate surgical repositioning.Orthodontic repositioning.
This paper describes the treatment of a mature permanent central incisor in which spontaneous re-eruption after severe traumatic intrusion occurred.
An 11-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry one day after trauma with the chief complaint of traumatized upper front teeth. She was treated at the Government Medical Hospital immediately after trauma. She was in good general health with no history of unconsciousness or bleeding from nose or ear after trauma. She was also given anti-tetanus cover post trauma.
On examination, sutures were present on the lower lip. Intra-oral examination showed markedly intruded 11, 21 (about 6 mm) with concomitant uncomplicated crown fracture with 21 [Figure 1]. Teeth were not tender to percussion and elicited a high-pitched metallic sound similar to ankylosed teeth. No associated alveolar fracture was detected.
Intra-oral periapical film demonstrated that both the central incisors were intruded, had closed apices and no pulpal or periapical pathology. The periodontal ligament space, around the roots was diminished, but no root or bone fracture could be detected [Figure 2].
At the initial appointment the intra-oral soft tissues were cleaned with saline and hydrogen peroxide. The patient was prescribed antibiotics and analgesics, chlorhexidine mouthwash, oral hygiene instructions were given and soft diet was advised.
Since the teeth presented with mature apices, prophylactic endodontic treatment was planned. So gingivectomy was performed to gain access to the root canal. The access opening was done, working length was determined and biomechanical preparation was completed; then the root canals were filled with non-setting calcium hydroxide paste (Vitapex) [Figure 3]. During one month follow-up spontaneous re-eruption of both the teeth by about 2 mm in 21 and 1 mm in 11 was seen. At three month follow-up, teeth erupted by about 4 mm in 21 and 3 mm in 11 [Figure 4]. Three months following trauma there was no resorption of roots, and teeth spontaneously re-erupted, it was decided to obturate the canals with guttapercha [Figure 5]. The patient was recalled at recommended intervals every three months. At the end of one-year follow-up, the teeth spontaneously re-erupted to their normal position and were in functional alignment with other teeth [Figure 6].
Spontaneous re-eruption has been suggested by Ellis in 1940 as the treatment of choice, for intrusive luxation to prevent further disturbance to the apical and marginal periodontal tissues.  It is based on the fact that many of these teeth particularly ones with incomplete root formation do erupt on their own.  But recently Faria et al. have shown that even teeth with mature apices re-erupt spontaneously.  The disadvantages of this approach are two-fold: One, periodontal surgery- e.g, gingivectomy is needed to gain access to the root canal while waiting for spontaneous re-eruption. Second, root resorption or ankylosis may occur during the observation period.
Owing to the high incidence of pulp necrosis i.e., 100% in mature teeth we decided to go for prophylactic root canal therapy to prevent other complications arising from the pulp necrosis. Endodontic treatment should be carried out two weeks after the injury and calcium hydroxide should be placed in the root canal as an interim dressing to prevent external root resorption it also helps in periapical healing and when tooth completely re-erupts it should be obturated with guttapercha. 
The difficulty of root canal access in severely intruded teeth can be overcomed by gingival surgery to allow access to the root canal, then endodontic treatment can be performed while waiting for spontaneous re-eruption.
Surgical repositioning was recommended by Skieller for teeth that are completely intruded into and embedded by gingival tissues. Immediate repositioning or exposure of the crown by surgical repositioning might facilitate bonding of orthodontic bracket for subsequent orthodontic repositioning. However, this method is strongly opposed by some authors because it may increase the risk of external root resorption, sequestration and loss of marginal bone support.
Orthodontic repositioning or 'forced eruption' has been suggested as a possible treatment alternative, which might allow for remodeling of bone and the periodontal apparatus. The intruded teeth may be repositioned for endodontic treatment within two to three weeks so that inflammatory resorption can be prevented or treated if present. On the other hand, some authors recommend that the injured tooth be left to re-erupt on its own and in those instances in which it does not do so, it should be extruded orthodontically. ,
The ideal treatment option is the one with the lowest probability of developing associated secondary complications. The aim of dental treatment is and always will be to maintain the tooth if possible, then if the long-term prognosis is limited retention of the tooth until the child has finished growing will preserve the alveolar bone and help to maintain the space, maximizing the treatment options available once the tooth has been lost.
We conclude that waiting for spontaneous re-eruption associated with gingivectomy and endodontic treatment is an alternative treatment for intrusive luxation in mature permanent teeth.
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