PEDIATRICDENTISTRY/Copyright @1985 by TheAmerican Academy of Pediatric Dentistry Volume7 Number2 The changing role of endodontics and orthodontics in the management ~f traumatically intruded permanent incisors Peter M. Spalding, DDS, MS Henry W. Fields, Jr., DDS, MS, MSD Dennis Torney, DDS, MS H. Bryan Cobb, DDS,MS Johnny Johnson, DMD Abstract and discuss the treatment and complications in view of the changing and contrasting literature regarding Disagreementremains regarding the optimal treatment these injuries. for intrusive luxation injuries to permanentteeth. Three problemsoften present themselves following intrusive luxation: impropertooth position, pulpal necrosis, and Literature Review internal or external root resorption. In the recent past, Traumatic intrusion is a form of luxation that dis- the accepted treatment was to allow the permanentteeth places the tooth in an apical direction. This injury is to reerupt spontaneouslyfor 6-8 weeks. If this did not characterized by comminution of the alveolar socket occur, orthodontic traction was applied. The pulpal status and expansion of the alveolus to permit the new po- of the teeth was monitored and either calcium hydroxide 1 therapy or conventional endodontics was instituted sition of the tooth. Upon percussion, the intruded following pulpal necrosis depending on the maturity of tooth elicits a metallic sound similar to an ankylosed the root end. Pulpectomyand a calcium hydroxide filling tooth -- distinguishing it from an unerupted tooth. material were also the treatment of choice if there was The intrusion may be so severe that the affected tooth evidence of internal or external root resorption. appears to be missing upon clinical examination. Recent evidence suggests that orthodontic repositioning Radiographic examination may reveal partial or total should commenceas soon as possible following the trauma obliteration of the periodontal ligament space. regardless of the stage of root development.Teeth with Intrusive luxation of permanent teeth occurs less open apices can be monitored. Those with closed apices frequently than other types of luxation and is asso- should be opened, the pulp extirpated, and the canal filled ciated far more often with maxillary teeth than man- with a calcium hydroxide material. This will reduce the dibular teeth. 1,2 Although it is the less commonform chanceof root resorption and provide a period of of luxation, it is reported to be the type which has monitoringprior to a definitive root canal filling. Two the poorest prognosis. 2,3 However, few systematic cases are presented that demonstratethese contrasting treatment techniques and possible complications. studies have appeared in the literature. A variety of therapeutic measures have been reported, but the op- timal method of returning the tooth to its normal po- sition4,~ remains to be determined. In the past, surgical repositioning and splinting have been recommended. This type of repositioning has Effective endodontic and orthodontic manage- serious pulpal and periodontal consequences. A sig- ment of traumatic intrusive luxation of the permanent nificantly higher percentage of marginal bone loss, teeth in children arid adolescents continues to chal- ankylosis, and pulpal inflammatory response have lenge the dental profession. Managementshould in- been demonstrated following surgical repositioning clude an accurate diagnosis and treatment that will of intruded teeth in comparison to permitting spon- result in the best prognosis. The purpose of this pa- taneouss reeruption or orthodontic repositioning, per is to present two instances of intrusive luxation It has been suggested that intruded permanent teeth 104 TRAUMATICALLYINTRUDIED INCISORS: Spalding et al. with incomplete root formation be permitted to re- erupt spontaneously since there is significant erup- tion potential of such teeth.4 If no eruption occurred within 2 months or root formation was complete, or- thodontic repositioning was advised.6 7 Although Andreasen conducted a retrospective in- Fie 2. Patient 1, initial vestigation of 189 luxated permanent teeth and found periapical radiograph of that the 23 intruded teeth ultimately demonstrated intruded permanent 96% incidence of pulpal necrosis, pulpectomy was maxillary incisors. Note not recommended initially unless pulpal necrosis was the incomplete root 1 formation and the ap- diagnosed. In teeth with complete root formation, parent absence of den- pulpal necrosis was treated with conventional en- tal or alveolar fractures. dodontics. In those with incomplete root formation, pulpal necrosis was treated with either pulpotomy or pulp extirpation followed by procedures to close the open apex.5 Another complication of intrusive luxation is root resorption. In Andreasen's study, 52% of the in- truded teeth were affected by either external replace- ment or inflammatory resorption.1 External root resorption was treated by either pulpectomy and a pulpal necrosis and the need to prevent root resorp- calcium hydroxide fill or conventional endodontics. tion. Teeth with immature root formation can be ob- A final problem frequently associated with trau- served for pulp necrosis and root resorption — therapy matically intruded permanent teeth is loss of mar- can be instituted immediately if necessary. 8 ginal bone support. Andreasen found this complication Turley et al. conducted an investigation studying with 48% of the intruded teeth and attributed such a spontaneous reeruption and orthodontic reposition- high incidence to the severity of the periodontal in- ing as treatment options for managing intrusive lux- jury and the delay in treatment.1 ation of permanent teeth in dogs. They traumatically It now appears that the appropriate treatment for intruded first premolars with completely formed ap- intruded teeth with or without complete root for- ices, subjected half of these teeth to orthodontic ex- mation is immediate application of orthodontic forces trusive forces, and allowed the other half to erupt to reposition the teeth in 3-4 weeks in order to avoid spontaneously. In their study, the more severely in- ankylosis and permit monitoring or early access for truded teeth exhibited ankylosis and failed to erupt endodontic treatment.5-8 For teeth with complete ap- or respond to orthodontic extrusion. The less se- ices, extirpation of the pulp followed by a calcium verely intruded teeth did not become ankylosed, but hydroxide fill is indicated within 14 days of the in- demonstrated some spontaneous eruption as well as jury. This has been advised due to the certainty of extrusion from orthodontic forces. In a later study, Turley et al.4 found that severely intruded (5-6 mm) teeth could be extruded ortho- dontically if they were luxated following the trauma. Their conclusions suggest that the severity of the traumatic intrusion and the amount of mobility pres- ent are important factors affecting the prognosis for spontaneous reeruption or orthodontic extrusion. Clinical Reports Two injuries are reported that demonstrate both the old and new treatment options recommended for intrusive luxation: allowing reeruption, and imme- diate orthodontic repositioning (as well as different timing for pulpal extirpation). The first report involved a 6-year, 11-month-old black Fie 1. Patient 1 (initial visit), showing 7 mm intrusion of the female injured in a fall on stairs at school. The patient permanent maxillary central incisors and 2 mm intrusion of was transported immediately to a hospital emergency the permanent maxillary right lateral incisor. room where her neurologic status was evaluated. No PEDIATRIC DENTISTRY: June 1985/Vol. 7 No. 2 105 neurologic problems were found, and subsequently primary maxillary second molars and canines, bonded she was referred to the pediatric dentistry clinic. The attachments on the intruded teeth, and elastic trac- medical history was unremarkable and immuniza- tion. This appliance delivered an extrusive force of tions were current. approximately 100 gm to each incisor. Extraoral examination was unremarkable except for At the appliance insertion appointment, a periap- a laceration on the lower lip. Intraoral examination ical radiograph revealed external root resorption in- revealed 7 mm intrusive luxations of the maxillary volving the maxillary central incisors. In order to central incisors and a 2 mm intrusion of the maxillary prevent progression of the pathologic resorption and right lateral incisor (Fig 1). The 3 intruded teeth were permit root end closure, calcium hydroxide pulpec- seated firmly in alveolar bone with no clinical mobil- tomies were planned. Since the teeth could not be ity. The mandibular central incisors demonstrated isolated for endodontic treatment due to their in- slight mobility without apparent displacement. There truded position, a decision was made to wait 1 week was no clinical evidence of traumatic involvement of with the expectation that orthodontic movement would any other teeth or alveolar structures. provide enough lingual access to perform the calcium Radiographs revealed no apparent fractures of the hydroxide pulpectomies. dentition or surrounding alveolar bone. The radio- One week following placement of the appliance (9 graphs confirmed the clinical impression of intrusive weeks posttrauma), approximately 1 mm of extrusive luxation and revealed that these teeth had incomplete orthodontic movement had occurred. Nevertheless, root formation (approximately 7/8 complete) with open the movement was still insufficient for adequate