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Table of Contents
CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 1  |  Page : 43-47

Emergency orthodontic management of luxated permanent anterior teeth: A report of two cases showing role of orthodontist in multidisciplinary approach.


1 Reader, Department of Orthodontics, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat, India
2 Professor & HOD, Department of Orthodontics, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat, India

Date of Web Publication7-Aug-2018

Correspondence Address:
A C Mashru
Reader, Department of Orthodontics, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Piparia, Vadodara-391760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-6486.238795

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  Abstract 


Traumatic luxation of permanent anterior teeth requires an appropriate emergency management and treatment plan. Very less data in literature is available regarding emergency orthodontic treatment in luxated teeth. Light orthodontic forces given in early period of trauma in selected cases can restore teeth in original position that can allow better periodontal healing. This article focuses on the principles which orthodontic specialist should consider while planning orthodontic movement of recently traumatized permanent teeth. Two cases are presented of emergency orthodontic treatment.

Keywords: Incisor trauma, emergency orthodontic treatment (EOT).


How to cite this article:
Mashru A C, Goje S. Emergency orthodontic management of luxated permanent anterior teeth: A report of two cases showing role of orthodontist in multidisciplinary approach. J Integr Health Sci 2014;2:43-7

How to cite this URL:
Mashru A C, Goje S. Emergency orthodontic management of luxated permanent anterior teeth: A report of two cases showing role of orthodontist in multidisciplinary approach. J Integr Health Sci [serial online] 2014 [cited 2021 Nov 30];2:43-7. Available from: https://www.jihs.in/text.asp?2014/2/1/43/238795




  Introduction Top


Traumatic injuries of teeth are one of the main reasons of emergency treatment in dental practice. A patient with traumatized teeth presents different type of challenge to a treating specialist.

Whenever significant time has been passed after dental trauma, it hampers immediate surgical repositioning. With severe periodontal injury there is always a significant risk of complications like pulp necrosis, root resorption, loss of marginal bone and ankylosis. Therefore, it is wise to initiate orthodontic treatment earlier as ankylosed teeth cannot be moved orthodontically later. Orthodontic appliances provide slow, gradual and precise repositioning over a period of time.

Though there are plenty of articles regarding emergency endodontic/periodontic management of dental trauma there are very few articles which discuss emergency orthodontic management (EOA) methodically.

This article aims at clinical principles of need-based emergency orthodontic treatment planning and case presentations in luxated but not avulsed permanent anterior teeth. Comprehensive orthodontic treatment in traumatized teeth is not in scope of this article.

Treatment timings for EOT:

EOT can be done from just after trauma up to 3 months.[1] Sometimes injuries like intrusion can be so severe that manual reduction is not possible. EOT is indicated in those cases.

In case of bleeding and soft tissue injuries, starting of EOT can be delayed for one or two days. Length of treatment should be ranging from 3 weeks to 4 months.[2]

Endodontic considerations along EOA:

External resorption may occur soon after injury due to inflammation. Inflammatory resorption can be intercepted by timely endodontic intervention.[3]

Mode of endodontic treatment depends upon maturity of the root of traumatized tooth.[4] Tooth with openroot apex:

  • Repositioning and stabilization with fixed splint/orthodontic appliance should be done without root canal treatment at the start if tooth is vital.
  • Vitality should be checked up at the intervals of one month.
  • If signs of pulp necrosis than removal of pulp and apexification should be done.


Tooth with closed apex (mature root):

  • Chances of pulp necrosis in intruded tooth are more in teeth with closed apex. Total pulp removal is indicated. So tooth with closed apex should be repositioned with orthodontic appliance with pulp extirpation at the start with calcium hydroxide paste in the root canals.[5]


Case 1:

A 14 year old girl came to the clinic with complaints of pain and inability to eat since she met with a moped accident before five days. Clinical and radiographic findings revealed that 12, 11 and 21 were luxated; firm in new position and severely tender [Figure 1]. 12, 41 and 42 were fractured also due to trauma. Pulpal response of the 11,12,21,41 and 42 showed negative response indicating loss of vitality. Patient was not able to chew since trauma occurred.
Figure 1: Pretreatment photographs and OPG of case 1

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After informed consent treatment plan of EOT was decided. PEA 0.018 MBT appliance setup was done in upper arch. A round nitinol 0.014” arch was initially placed and loosely tied. Along with the fixed orthodontic appliance, necrosed pulp from the 11, 21 and 12 was removed. Calcium hydroxide root canal dressings were given in the affected incisors during active orthodontic treatment. Final root canal fillings were done after six months of trauma. Use of soft brush and rinsing with chlorhexidine 0.1% was advised.

Upper 0.014 nitinol wire was at work for one and half month. Then 0.014 nitinol was replaced by 0.016 round nitinol arch [Figure 2]. After one month 0.016 X 0.022 nitinol wire was at work for the rest of the alignment. With relief from the interference and pulp removal from the infected teeth, pain was completely relieved. Total time for active treatment was four and half months and then appliance was removed [Figure 3]. 26 were grossly carious with poor prognosis. So it was extracted.
Figure 2: Treatment progress: case 1

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Figure 3: End of EOT: case 1.

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Upper incisors were given a bonded retainer made up of spiral wire. Patient was checked after six months. There was no mobility or infection present.

Case 2:

A 15 yrs old boy came to clinic with complaint of severe pain and swelling in relation to upper front teeth. He had met with a bike accident before eight days. Clinical and radiographic examination revealed that 11 and 12 were luxated, severely tender and intruded. 21 and 41 were fractured also due to traumatic impact. They were firm in new position. Upper anterior teeth were severely crowded [Figure 4]. Pulp-vitality testing in 11,12,21,31 and 41 showed negative response depicting necrosed pulp. Unerupted mesiodens was also visible in the OPG. Palatal gingiva was swollen and pus discharge from the crevices was present. Due to luxative injury occlusion was interfered and patient was not able to chew. He was having habit of chewing tobacco.
Figure 4: Pretreatment photographs and OPG of case 2

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After informed consent treatment plan for EOT in upper arch along with required endodontics was made. After EOT patient was advised surgical removal of unerupted mesiodens to be followed by comprehensive orthodontic treatment. Patient opted for EOT only and rejected other treatment options.

With upper 0.018 slot MBT appliance, unlocking was started with 0.014 nitinol wire [Figure 5]A. Due to severe luxation and intrusion endodontic access for upper right incisors was not possible initially. Upper right incisors relieved from the interference by light forces generated with 0.014 nitinol arch. Necrosed pulp was removed from the root canals of 11, 12 and 21. Pus discharge from the palatal gingival crevices was then stopped [Figure 5]B.
Figure 5: A-C show treatment progress: case 2;

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0.014 nitinol was replaced by 0.016 round nitinol to continue movement and total relief of the occlusion. Upper right canine was firm and used as anchorage to relieve the incisors. Active treatment time was four months. [Figure 6] shows end of EOT. Root canals were obturated after appliance removal. Upper Howley retainer was given. Scheduled check after six months showed no abnormalities.
Figure 6: End of EOT: case 2

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  Discussion Top


It has been shown that in mild(less than 3mm) to moderate (3-6 mm) intrusion orthodontic reposition is better option than surgical reposition.[5]

Mild and moderately traumatically intruded teeth can be best treated by orthodontics.[6] Dentitions in both our cases were having mature root apices and offending teeth were nonvital after several days of trauma. In both of the cases injured teeth were too firm to manipulate as a few days has been passed.

In case 1 immediate repositioning to be followed by splint was also an option against orthodontic movement. On clinically looking there were all chances of teeth avulsion during surgical reduction. For that reason slow movement with light forces was selected in case 1.

In both cases patients had come for emergency treatment only. After thorough consultation including various treatment options both patients opted for need based emergency treatment only. Objectives of the treatment were to reduce the traumatic luxation via light orthodontic forces and relief of the occlusion from the interferences. Case 1patient recalled that front teeth were “in line” before trauma. In case 2 at the start of the EOT patient was informed about comprehensive treatment in future along with the surgery for the removal of mesiodens. He refused to accept treatment other than EOT. So OPG and IOPA were only radiographs advised at the start. As comprehensive treatment was denied by patient cephalometric assessment was not required.

In both cases patient met with severe automobile accident. Traumatic ulcers due to bruises and lacerations in upper lip mucosal area were present. In case 2 both the upper canines were also “high” in the vestibule. So at start of the treatment it was felt that putting Begg's brackets and lockpins could aggravate already existing ulcers. This may had led to increase in pain and delay in healing the affected area. So PEA 0.018” MBT system was chosen to minimize irritation.

In case 2 teeth were crowded that would have made splinting much difficult. Traumatized teeth were luxated towards the palatal gingiva leading to almost flushed palatal surface and adjoining gingiva. So gingivectomy on palatal side along with splinting would be utmost difficult. So relief of the occlusion and alignment with the orthodontic mechanotherapy was chosen in case 2. Pulp removal in 11 and 12 was done after some extrusion and forward movement took place with light orthodontic forces. That movement provided enough entrance on palatal surface for preparation of gain access cavity. It has been shown that the occurrence of root resorption after intrusive trauma appears to be related to the severity of the original injury and the stage of root development rather than the repositioning procedure.[7]

Prevention of incisor trauma:

It has been demonstrated that individuals with an increased overjet are at significantly greater risk of dental injury. An increase in overjet from 0-3 mm to 3-6 mm doubles and an overjet which exceeds 6 mm trebles that risk.[8]

For this reason, early elective orthodontic treatment is often the treatment of choice for individuals with significant overjet. Many dentoalveolar sports injuries can be prevented by the use of mouthguards, preferably vacuum-formed.[9]


  Conclusion Top


Emergency orthodontic treatment in traumatically luxated teeth along with endodontics can give superior output in terms of survival, function and esthetics. This simple mechanics applies light forces which can minimize future complications. The orthodontist is one of the most skilled professional able to apply appropriate directional forces to resolve luxative displacement. Any repositioned teeth should be monitored for future complications like root resorption and marginal bone loss.



 
  References Top

1.
Moule AJ, Moule CA. The endodontic management of traumatized permanent anterior teeth: a review. ADJ Supplement 2007; 52 :( 1 Suppl):S122- S137.  Back to cited text no. 1
    
2.
Chaushu S, Shapira J et al. Emergency orthodontic treatment following the traumatic intrusive luxation of maxillary incisor teeth. Am J Orthod 2004; 126(2):162-172.  Back to cited text no. 2
    
3.
Andreasen FM, Andreasen JO. Diagnosis of luxation injuries: the importance of standardized clinical, radiographic and photographic techniques in clinical investigations. Endod Dent Traumatol 1985; 1:160-169.  Back to cited text no. 3
    
4.
Clinical guideline on management of acute dental trauma. AAPD. Guideline on management of acute dental trauma Chicago (IL): AAPD; 2007. 14p.  Back to cited text no. 4
    
5.
Kinirons MJ. Traumatically intruded permanent incisors: a study of treatment and outcome. Br Dent J 1991; 170:144-146.  Back to cited text no. 5
    
6.
Andreasen JO, Andreasen FM. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Dental Traumatology, 2006; 22(2): 99-111.  Back to cited text no. 6
    
7.
Sondos A et al. Factors affecting resorption in traumatically intruded permanent incisors in children. Dental Traumatology 2002; 18:73–76.  Back to cited text no. 7
    
8.
Malmgren O, Malmgren B, Goldson L. Orthodontic management of the traumatized dentition. In Textbook and color atlas of traumatic injuries to the teeth (4th edition.) Copenhagen,2007. pp. 669-709.  Back to cited text no. 8
    
9.
Anthony JD, Bakland LK. Traumatic dental injuries: current treatment concepts. Journal of American Dental Association. 1998; 129:1401-1414.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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