Treatment of traumatically intruded permanent incisor teeth in children. BSPD reviewed guidelines Albadri S, Zaitoun H, Kinirons MJ Introduction Traumatic intrusion is a luxation injury where the tooth is axially displaced into the alveolus. Although, this type of injury is more common in primary teeth, it is considered one of the most severe luxation injuries affecting permanent teeth. Intrusion injuries are often associated with severe damage to the tooth, periodontium and pulpal tissue. There is a lack of general agreement and scientific evidence concerning the best treatment for traumatically intruded permanent teeth in children. The rare occurrence of this injury, 0.3-1.9% in the permanent dentition (1), has resulted in limited studies to support suggested treatment regimes. However, the following guidelines are based on the available evidence and are intended to be of assistance to practitioners who may be involved in the management of such cases. Further details are available under Summary of literature. 1. Initial management: History and examination. A thorough medical and dental history should be obtained together with details of how, when and where the accident occurred; these should be carefully recorded. A large degree of force is required to severely intrude permanent incisor teeth. Therefore, one should be alert to the possibility of other injuries, including injuries to the head and facial region. In the established dentition, diagnosis is based on a difference in the position of the incisal edges of affected and unaffected teeth whereas in the mixed dentition a high metallic note on percussion is indicative of intrusion or lateral luxation. Radiographic examination with more than one view as recommended by the International Association for Dental Traumatology guidelines (2) is necessary and may reveal differences in apical levels, alveolar fractures or signs of damage to adjacent teeth. 2. Treatment Extra- and intra-oral lacerations and wounds should be cleaned and sutured as appropriate. Systemic antibiotic treatment and tetanus boosting may be required if external contamination has occurred. Decisions regarding treatment may vary according to the maturity of the root and the severity of intrusion. There are three available modalities of treatment: Passive repositioning (PR), to allow the tooth to re-erupt. Active repositioning including; o Immediate surgical repositioning (SR). o Orthodontic repositioning using removable or fixed appliances (OR). Intrusion Guidelines Review / /August 09/ Final/V2 1
Root development has been shown to be an important determinant for the success of passive repositioning (3, 4). Table 1 summarises treatment guidelines for intruded permanent incisors. The aim of treatment is that the tooth is maintained if possible, but very severe injuries may require tooth extraction in some circumstances. 2.1 Repositioning of teeth with incomplete root development 2.1.1. (Grade B) Mildly intruded (< 3mm) with incomplete root development. These can be managed conservatively due to their eruptive potential. Allow re-eruption and review. 2.1.2. (Grade B) Moderately intruded (3-6 mm) with incomplete root development. These teeth may erupt if managed conservatively. If no movement is evident within 2-3 weeks, orthodontic repositioning should be performed. A removable appliance with a selfsupporting spring or elastic module could be used to apply vertical extrusive force to the tooth through a bonded bracket onto the labial or incisal region (5). Orthodontic extrusion can take 3-4 weeks. 2.1.3. (Grade B) Severely intruded (>6 mm) with incomplete root development. Again a conservative approach allowing initial passive repositioning followed by orthodontic repositioning if no movement is evident in 2-3 weeks. The benefit of allowing passive repositioning is a reduced risk of healing complications (6). Although this approach includes severely intruded teeth, clinical judgement and preference may favour surgical repositioning in very severe cases especially where there are concomitant injuries of adjacent teeth, which require splinting. If in doubt, consider getting advice from, or referring to, a specialist centre for treatment. Repositioning technique: local anaesthesia should be administered and the tooth should be gently repositioned. Repositioning can normally be accomplished by very gentle movements using a sterile flat plastic instrument. In resistant cases, consider the possibility of bony impaction and release of the impediment prior to repositioning of the labial plate of bone and soft tissue closure and suturing. In some cases sedation or even general anaesthesia may be required. 2.2 Repositioning of teeth with complete root development 2.2.1. (Grade B) Mildly intruded (< 3mm) with complete root development. These teeth may erupt if managed conservatively. If no movement is evident within 2-3 weeks, or if early signs of tooth rigidity are noted, start orthodontic repositioning. 2.1.2. (Grade B) Moderately intruded (3-6 mm) with complete root development. Active repositioning using either surgical or orthodontic repositioning. The relative merits of these two treatments is unproven, although surgical repositioning involves a reduced number of visits and allows rapid access to the root canal for any root canal therapy. 2.2.3. (Grade B) Severely intruded (>6 mm) with complete root development. Surgical repositioning and any appropriate tissue repair; this is best undertaken in a specialist centre. Intrusion Guidelines Review / /August 09/ Final/V2 2
3. (Grade C) Splinting of repositioned teeth Intruded teeth that are surgically repositioned require appropriate splinting. A non rigid (flexible) splint should be used to stabilise the traumatised tooth, whilst allowing physiological tooth movement. There are a number of non-rigid splints including composite and wire splints (7) and removable splints (8). The choice of splint depends on the facilities available and the clinical situation (e.g. patient in mixed dentition stage, multiple teeth injuries). The splinted tooth should be out of traumatic occlusion. In all cases the tooth should be reviewed within one week of the accident to assess the healing process, check and adjust the splint if necessary. Although, Andreasen et al. (9) recommend a splinting period of 6 to 8 weeks following surgical repositioning, a shorter period of 10 days has been shown to permit sufficient reduction in mobility to allow function (3). 4. Antibiotic Treatment (Grade C): The benefit of systemic antibiotic treatment upon pulpal or periodontal healing is unproven (10). However, the use of antibiotics is governed by clinical judgement (e.g. contamination, associated hard and soft tissue injuries). 5. Follow-up management 5.1. (Grade B) Root Canal Therapy 5.1.1. Teeth with incomplete root development Teeth with incomplete root development should be monitored closely with root canal treatment being indicated only following diagnosis of pulp necrosis (3, 10). Where root canal treatment is required, an apical barrier should be achieved prior to obturation (11). 5.1.2. Teeth with complete root development In view of the very high risk of loss of pulpal vitality, root canal treatment is often indicated in cases of moderate to severe intrusion. There is also a high risk of root resorption in these teeth (4). The recommended time to start root canal treatment is approximately two weeks after the injury. In cases of severe intrusion this early endodontic therapy is facilitated by rapid surgical repositioning. In the presence of inflammatory root resorption the canal should be dressed with non setting calcium hydroxide paste with appropriate replacement until root resorption is controlled before obturation (12). 5.2 (Grade B) Prognosis Intrusive luxation in permanent teeth has been associated with severe complications, especially pulp necrosis, external root resorption and marginal bone loss. Parents and patients can be informed of the range of clinical outcomes associated with intrusive luxation. Table 2; summarises the findings of available outcome studies on the long term prognosis and survival of intruded permanent teeth. Intrusion Guidelines Review / /August 09/ Final/V2 3
6. Additional considerations and summary of the literature: The optimal treatment of intruded permanent teeth has always been controversial. There are no randomised control trials comparing the available treatment options. However, in the last 10 years retrospective clinical studies have been published, the largest of which had a sample of 140 teeth (13). In teeth with immature root development, waiting for re-eruption (passive repositioning) should be the treatment of choice as it is reported to be associated with fewer complications (3, 10). In the past many authors suggested that surgical repositioning may increase the risk of loss of marginal bone support. However, outcome studies have suggested that healing complications are associated more with the severity of the injury rather than the mode of treatment (4, 14). The choice between orthodontic and surgical repositioning remains an area of debate. In those teeth with complete root development and severe intrusion (>6mm) surgical repositioning will allow access to start root canal treatment. An animal in vitro study (15) reported that surgical repositioning of severely intruded permanent teeth with complete root development resulted in more normal orientation of the periodontal fibres and consequently less replacement resorption as the fibres are under less tension with respect to the cementum and bone walls. In addition, Andreasen et al. (10) favoured surgical repositioning of moderate to severely intruded teeth with complete root development as it is potentially less time consuming, requiring fewer patient visits. The International Association for Dental Traumatology (2007) (2) recommended that for immature teeth, if passive repositioning is not evident within 3 weeks then rapid orthodontic repositioning should be commenced. With regard to teeth with complete root development, active repositioning either orthodontic or surgical is recommended from the outset. Furthermore no consideration is given to the severity of intrusion when determining treatment options. Intrusion Guidelines Review / /August 09/ Final/V2 4
Table 1: Summary of treatment recommendations for intruded incisors Incomplete root development Complete root development Mild (<3mm) PR PR after 2-3 weeks OR ** Moderate (3-6mm) PR * SR or OR *** Severe (>6mm) PR* SR * If Passive repositioning (PR) not working within 2-3 weeks start Orthodontic repositioning (OR) ** PR in preference to OR, i.e. not personal preference. If PR not working within 3 weeks start OR *** OR and surgical repositioning (SR) both appropriate, however SR often involves fewer visits Table 2: Summary of the outcome of traumatically intruded permanent teeth (3-6, 10, 14&16) Complication Pulp necrosis Root resorption Marginal bone loss Survival All stages of root development (RD) 45-96% 11-80% 6-48% 69-95% Incomplete RD 61-67% 42-68% 5% - Complete RD 88-98% 51-73% 44% - Intrusion Guidelines Review / /August 09/ Final/V2 5
References: 1. Andreasen JO, Bakland LK, Matras R, Andreasen FM. Traumatic intrusion of permanent teeth. Part 1. An epidemiological study of 216 intruded teeth. Dental Traumatology 2006; 22: 83 89. 2. Flores, MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trop M, Tsukiboshi M, von Arx T. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology 2007; 23: 66-71. 3. Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusion. Dental Traumatology 2003; 19: 266-273. 4. Albadri S. Kinirons M, Cole B, Welbury R. Factors affecting Resorption in traumatically intruded permanent incisors in children. Dental Traumatology 2002; 18: 73 76. 5. Chaushu S, Shapira J, Heling I, Becker A. Emergency orthodontic treatment after the traumatic intrusive luxation of maxillary incisors. American Journal of orthodontic and Dentofacial Orthopedics 2004; 126: 162-172. 6. Kinirons MJ, Sutcliffe J. Traumatically intruded permanent incisors: a study of treatment and outcome. British Dental Journal 1991; 170: 144-146. 7. Brown CL, Mackie IC. Splinting of traumatized teeth in children. Dental Update 2003; 30: 78-82. 8. Saunders IDF. Removable appliances in the stabilisation of traumatised anterior teeth. Proceedings of the British Paedodontic Society 1972; 2: 19-22. 9. Andreasen JO, Andreasen FM, Andersson L. Text book and color atlas of traumatic injuries to the teeth. 4 th edition. Blackwell; 2007. 10. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Dental Traumatology 2006; 22: 99 111. 11. Mackie IC. Management and root canal treatment of non-vital immature permanent incisor teeth (UK National Clinical Guidelines in Paediatric Dentistry). International Journal of Paediatric Dentistry 1998; 8: 289-293. 12. Trope M, Moshonov J, Nissan R, Buxt P, Yesilsoy C. Short vs. long-term calcium hydroxide treatment of established inflammatory root resorption in replanted dog teeth. Endodontics and Dental Traumatology 1995; 11: 124-128. Intrusion Guidelines Review / /August 09/ Final/V2 6
13. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 2. A clinical study of the effect of preinjury and injury factors, such as sex, age, stage of root development, tooth location, and extent of injury including number of intruded teeth on 140 intruded permanent teeth. Dental Traumatology 2006; 22: 90 98. 14. Ebeleseder KA, Santler G, Glockner K, Hulla H, Pertl C, Quehenberger F. An analysis of 58 traumatically intruded and surgically extruded permanent teeth. Endodontic and Dental Traumatology 2000; 16: 34-39. 15. Cunha RF, Pavarini A, Percinoto C, Lima JE. Influence of surgical repositioning of mature permanent dog teeth following experimental intrusion: a histological assessment. Dental Traumatology 2002; 18: 304 308. 16. Andreasen JO. Luxation of permanent teeth due to trauma. Scandinavian Journal of Dental Research 1970; 78: 273-286. Intrusion Guidelines Review / /August 09/ Final/V2 7