NEWSLETTERS

Trauma-generated intrusive impaction of previously erupted teeth

Published: March 2012

Bulletin #9 - March 2012

Trauma-generated intrusive impaction of previously erupted teeth

Typically, the child is seated in the waiting area of the ER of a local hospital, holding his bloodied mouth and face in a wad of Kleenex tissues. Mother is crying unconsolably and the concerned father or perhaps the school teacher explains that the child fell at school in the late afternoon and had knocked out his four upper front teeth. The alert teacher had recruited the assistance of the boy’s classmates and together they had made a search for the lost teeth, but could not find them on the classroom floor/in the school playground/at the sports field or wherever else the traumatic episode had occurred.

The local hospital has no dental department per se and the duty oral and maxillofacial surgeon is already at the golf course. The child is referred to a local dentist and from there to a local pediatric dentist or perhaps another OMFS and he is examined for the first time. A radiograph is taken and, to the surprise of all concerned in this hypothetical scenario, it is found that the teeth have not been knocked out, but have been pushed upwards into the alveolar process, have become buried in the torn gingival tissues and all but lost from sight. Moreover, a closer examination of the film shows that the teeth are complete and their roots are not fractured.

Concurrently, the oral tissues are bleeding profusely and, while hemostasis is relatively easy to achieve, this is often a serious concern at the time due to its frightening appearance. It is usually the least of the problems in the medium to long term because oral tissues heal very well and very quickly – possibly with the help of a few sutures in the lip or tongue.

As with many of these emergency situations, the treatment advised may depend more on this dental practitioner’s specialty or specific interest which may influence what is perceived as being best for the patient. Thus, the pediatric dentist is likely to suggest a period of waiting to see if the teeth will re-erupt spontaneously, as has been described in a number of case reports. The OMFS may recommend immediate surgical repositioning of the displaced teeth, followed by fixed splinting. The generalist may prefer to call a colleague for further advice, because it is not really his/her area - but it is now evening! The only other person available is the orthodontist in the next office who is busy straightening teeth after school hours.

When incisor teeth are intruded in this manner – and it is almost invariably maxillary incisor teeth - they are wedged upwards in a conical socket, which is narrowest at the top end. In this type of traumatic displacement, the periodontal fibers supporting them are more or less completely severed and the labial plate of the socket wall is fractured and displaced further labially to increase the width of the sockets, driven by the wedging movement of the wider part of the tooth. Essentially, the situation is one of a complete avulsion of the tooth, with little or no periodontal fiber support, but the tooth remains in a blood-rich environment and is thus at an advantage in comparison with a tooth that has been totally avulsed, fallen out of the mouth and subsequently re-implanted.

TREATMENT

It is now generally recommended to leave the teeth in place and hope for the spontaneous re-eruption of the teeth that appears to occur in a fairly high proportion of cases, while attending to the collateral damage that has occurred to the soft tissues of the mouth and face. If reduction occurs in this way, it seems that the long term damage will be less than will occur after active reduction of the displacement.1-3

For the most part, therefore, the treatment decision should be to wait for the teeth to re-erupt spontaneously, but it is important to accept that not more than a week or two should be allowed to elapse, since signs of re-eruption are usually seen within a few days. If these signs are seen, then it is always worth waiting for a further few weeks to obtain the maximum spontaneous benefit available. It appears that the chances of resolution are better when the affected tooth has an open apex. In the absence of early signs, reduction of the displaced teeth needs to be made by alternative means.

The surgical option

In the surgical option for reduction of the impaction, it will be realized that simply re-locating the teeth in their former positions does not take into account the absence of a supporting socket wall, at least on the labial side but possibly also on the palatal side. The fractured labial and/or palatal process must also be re-located around the teeth and the gingivae sutured back to close off the tissues. The teeth must then be splinted in this position until their bony support has provided them with some stability. The danger is that they may be easily displaced and lost, in the short term. The reader is referred elsewhere for a fuller description of the techniques involved with the surgical option and their relative merits.4

The orthodontic option

Is there an orthodontic option? The orthodontist is on hand, in that fateful evening, to provide whatever assistance that may be indicated. The problem is that he/she was taught in graduate school that, following trauma to the anterior teeth, orthodontic treatment should not be started, or an ongoing treatment be discontinued, for a period of 3-6 months after the teeth have become symptomless and after any apical pathology has been resolved. On the other hand, if he/she is to deny treatment to our hypothetical trauma patient for this length of time, the chances of these teeth becoming ankylosed in this position would be high, the teeth would be immovable and we would have a very unhappy patient.

There are also other dilemmas that may mitigate against considering an orthodontic option. The teeth are almost completely buried in hemorrhagic gingival tissue and one cannot possibly place brackets at the appropriate height, angle and location without first performing gingival surgery. Furthermore, if we apply extrusive traction to teeth whose periodontal fibers have been completely severed from the surrounding bone of the socket walls, are we not likely to find the teeth jangling loosely on our orthodontic wires in the patient’s mouth, like some Amazon Indian’s trophy necklace, before we can say Jack Robinson!?

Notwithstanding these important reservations, a good orthodontic option does exist and it should be carefully considered, because it has advantages for the patient in the long term.5

The prerequisite is that nothing be done to move these displaced teeth in the immediate post-trauma period, until a period of healing has passed, in which some re-attachment of the severed periodontal fibers will have taken place and until we have confirmed that signs of the hoped-for spontaneous re-eruption have not appeared. This usually means waiting for a period of 2 to 3 weeks, during which time debridement is carried out and the area cleaned with gentle brushing and antiseptic mouthwashes. Antibiotics should be used, as deemed necessary and the area maintained as free from infection as possible.

The next task is to construct an appliance that is firm and rigid on the one hand, yet able to apply a measurably light extrusive force to these teeth, either as a group or, if necessary, individually. The following is a description of an appliance that is recommended here.

The appliance

I know that you only have molar bands pre-welded with triple tubes and a hook, but please try to find well-fitting plain (without pre-welded attachments) molar bands and place them on the maxillary first molars. Take a “pick-up” impression with the bands in place and then carefully remove the bands from the teeth and re-locate them in the impression. Cast a model and have your orthodontic technician solder a “cut-back” design palatal arch in 0.036” stainless steel wire. Solder a round 0.036” buccal tube to the molars. An 0.036” self-supporting stainless steel labial arch is then fabricated on the model, to lie a couple of millimeters labial to the anterior teeth/ridge and parallel to the occlusal plane, when it is slotted into the buccal tubes on the molar bands.5 The appliance is transferred to the mouth and tried in, to check for proper fit, before cementing the bands and palatal arch in place.

Now comes the ticklish part! The minimum requirement for the intruded anterior teeth is that a millimeter or two of their incisal edges are exposed. If one or more of the teeth are completed covered by gingival tissues, then a very conservative trimming of the gingival should be done to achieve this. A small eyelet must now be bonded to this small exposed area on each of the teeth.

The self-supporting labial archwire is replaced in the molar tubes and, in its passive position should be such that it stands a few millimeters inferior to the eyelets. Soft steel ligature wires are threaded through each of the eyelets and secured around the slightly raised labial archwire. This will have generated a light extrusive pressure, with a wide range, on the incisors and the force exerted is easily measurable with a force gauge. The patient is seen weekly over the next month or two, to renew the force, as the teeth respond to the traction and until the teeth are relocated in their original positions.

In the event that the teeth do not respond, it usually means that one or more of them has established a bony connection and will need to be surgically re-luxated. It only takes one of the teeth to be ankylosed for it to prevent extrusive force being brought to bear on the others, if they are all ligated to the labial arch. The re-luxation may be done immediately or it may be delayed until the other teeth have reached their optimum locations, by separating the presumed ankylosed tooth from the extrusion appliance.

It is on record that when the intruded teeth have already completed their root apexification, the chances of retaining vitality are virtually nil. With teeth whose apices are still open, approximately half will recover their vitality, while the remainder will become non-vital.3 However, there is plenty of opportunity during this treatment period, from the day of the accident, to consult with an endodontist or a pediatric dentist to decide what and when endodontic treatment should be carried out. This is not merely a good idea, this is one of the essential interdisciplinary decisions that must be taken from the earliest opportunity after the accident and serially reviewed throughout.

Initial_jpg

Fig. 1 a, b. Soft tissue lacerations were sutured on the day of the trauma and the patient was referred for orthodontic extrusion.

Fig._1._initial_pan_October_2009

Fig. 2. Panoramic view of patient in early October 2009, immediately after the trauma incident, showing the four maxillary incisors displaced high above the occlusal plane, displaying no root fractures.

In the example that I have taken from my treatment files, the boy was 12 years old and had received a blow to the front of the mouth, which resulted in the total intrusive luxation of all four maxillary incisors to gum level (Fig. 1). He first attended my office 5 days after the episode, having been referred by a general dental practitioner and a pediatric dentist. The incisal edges of the left central and lateral incisors were barely seen and the same teeth on the right side were covered under the swollen and lacerated gums. He was seen again 2 weeks later, in the absence of signs of spontaneous eruption of any of the teeth.

Perhaps the biggest potential problem, was that the fact that the parents were both lawyers!! In fact, they turned out to be excellent, understanding, supportive and model parents.

Fig._2._October_2009_6857

Fig. 3. The extrusion appliance consists of a palatal arch soldered to two molar bands, with a removable steel self-supporting archwire, which slots into soldered round cross-section buccal tubes.

Fig._3_October_2009

Fig. 4a, b. Despite a post-trauma observation period of 3 weeks, no spontaneous eruption was noted and active intervention was initiated in late October 2009. Small eyelets were bonded to the exposed incisal edges of the 4 incisors, at gum level and the archwire slotted into the molar tubes, seen here in its passive position.

Fig. 4c. The occlusal view shows the soldered palatal arch resting lightly on the palatal mucosa, to provide anchorage resistance to the extrusive forces.

Fig. 4d. The anterior portion of the labial archwire has been raised (compare with Fig. 3b above) and ligated to the eyelets, generating light extrusive force on all four at once.

Molar bands with soldered palatal arch, of the same design as noted above (Fig. 3), were cemented into place and, after gently displacing the covering gingiva, eyelet attachments were bonded to the incisal edges of the 4 incisor teeth (Fig. 4). Light traction was applied immediately (Fig. 4d) and the patient re-scheduled for follow-up 10 days later. The attachment on one tooth debonded twice in the first week and had to be rebonded. During this time the child was seen by his dentist on several occasions, to open the root canals of the affected teeth and fill with calcium hydroxide paste.

Fig._4_November_2009

Fig. 5a, b. Seen several times in the next month, the teeth did not respond to the extrusive forces, but the banded permanent molars could be seen in November 2009 to be intruded and the palatal arch becoming buried in the palatal mucosa. Ankylosis of one or more of the incisors was presumed.

After 2 visits and a gradual increase in the extrusive force, no progress was seen, but it was noted that the palatal arch had become embedded in the palatal tissue, with associated pain and swelling and the banded molars were intruded (Fig. 5).

Fig._5._December_2009

Fig. 6. It was unclear which of the teeth was responsible and the appliance was arbitrarily separated from the right side incisors. In December 2009, the left side incisors had erupted to occlusal level and the eyelets on the left side and the labial arch were removed. The palatal arch was left in place for a period of 3 weeks to permit the compressed, swollen but asymptomatic palatal tissues to rebound and re-extrude the molar teeth.

The labial arch was removed for a week and then replaced to apply force only to the left incisors, which erupted quickly (Fig. 6). When the same procedure was adopted for the right side incisors, there was no response. However, the maxillary first permanent molars had become intruded in relation to the occlusal level of the teeth anterior to them and the palatal arch again became embedded in the palatal mucosa. It was judged that ankylosis had occurred in at least one of the teeth. To relieve the problem, the labial arch was removed for 3 weeks, by which time the molars had re-erupted and pressure on the palatal tissue had subsided.

Fig._6.January_2010

Fig. 7. In January 2010, the palatal arch was removed and re-cemented with an acrylic Nance button added, to increase the anchorage value of the unit. Traction was again applied to the right incisors but, this time, the teeth were subjected to surgical luxation to facilitate their eruption by breaking the presumed ankylotic connection to the alveolar bone.

The molar bands and soldered palatal arch were removed and then replaced on the same day with the addition of an acrylic Nance button (Fig. 7), to provide improved and more comfortable resistance against the palatal tissue. There was no response from the right central nor lateral incisors to elastic tie force individually on each. Accordingly 4 weeks later, a local anaesthetic was administered and these teeth were luxated with forceps until a considerable mobility was achieved. They were reconnected to the labial archwire and immediate extrusive force re-applied. Two further luxations were needed before the teeth finally surrendered and then they moved very rapidly to reach the occlusal level.

Fig._7._July_2010

Fig. 8. By July 2010 and after 2 more surgical luxation procedures, followed by immediate traction, all four incisors had erupted and regular orthodontic brackets were substituted in their ideal locations on the teeth to achieve a minimal degree of alignment. Three weeks later, appliances were removed, the remaining deciduous teeth were extracted and a simple removable Hawley retainer placed for a few months nocturnally, to maintain space until the premolars and canines had erupted. No further orthodontic treatment has been performed since this time. Root canal treatment with calcium hydroxide was performed on several occasions over the period, by the general practitioner, once there was access to the teeth from the palatal side.

With normally displayed labial surfaces of all four incisors visible, orthodontic brackets were substituted for the eyelets and left in place for 4 weeks to achieve an acceptable alignment (Fig. 8). The appliance was removed (Fig. 8c) and a simple removable retainer inserted in its place, the purpose of which was to passively retain the achieved alignment and to maintain space posteriorly, following the extraction of the remaining deciduous teeth. This was worn at nights only for a further 4 months.

Trauma, in general and ankylosis treated in this way, in particular, must be considered strong candidates for future ankylosis to occur or recur. It is for this reason that a reasonable alignment should be aimed for at this stage. However, unnecessarily extending the duration of treatment to these teeth in order to obtain “the perfect” alignment, is strongly ill-advised, since superfluous manipulation may itself increase the risk.

Fig._8._July_2010

Fig. 9. The July 2010 periapical and panoramic views of the dentition show the temporary calcium hydroxide root fillings. They also show some foci of external root resorption.

Fig._9._February_2012

Fig. 10. Follow-up views of February 2012 show minor worsening of the resorption on the right lateral incisor, but not elsewhere.

Follow-up should be turned over to those involved with the endodontic care of the patient and their aim will be to try to minimize the type and severity of root resorption that always accompanies teeth that have been traumatized in this way (Fig. 9). Orthodontic follow-up and the consideration of whether to undertake further orthodontic treatment should be decided in consultation with the endodontist and there is no urgency in arriving at this particular decision (Fig. 10) - indeed, delay may be beneficial in that it contributes additional information regarding the prognosis of the affected teeth.

Fig._10.February_2012

Fig. 11. Seen in February 2012, the alignment has improved markedly and spontaneously, without resorting any form of appliance therapy. The teeth show normal mobility and excellent gingival appearance. There is an unexplained lateral open bite on the right side, which does not seem to be related to the trauma episode. The advisability of offering orthodontic treatment for the present condition will be reconsidered in a year’s time, following a re-evaluation of the status of the root resorption.

It should always be remembered that the enemy of an acceptable result (Fig. 11) may well be the aim to achieve a perfect result!

References

1. Wigen TI, Agnalt R, Jacobsen I. Intrusive luxation of permanent incisors in Norwegians aged 6–17 years: a retrospective study of treatment and outcome. Dental Traumatology 2008; 24: 612–618.

2. Tsilingaridis G, Malmgren B, Andreasen JO, Malgren O. Intrusive luxation of 60 permanent incisors: a retrospective study of treatment and outcome. Dental Traumatology, Published online 2011; doi: 10.1111/j.1600-9657.2011.01088.x

3. Chaushu S, Shapira J, Heling I, Becker A. Emergency orthodontic treatment after the traumatic intrusive luxation of maxillary incisors. Am J Orthod Dentofac Orthop 2004;126:162–72.

4. Andreasen JO, Andreasen FM Intrusive luxation in Andreasen JO, Andreasen FM, Andersson L, (eds) Textbook and Color Atlas of Traumatic Injuries to the Teeth (4th ed). Oxford: Blackwell/Munksgaard, 2007;428-443

5. Chaushu S, Shapira J, Heling I, Becker A. Emergency orthodontic treatment following the traumatic intrusive luxation of maxillary incisor teeth. Am J Orthod Dentofac Orthop 2004; 126:162-172

6. Becker A. The orthodontic treatment of impacted teeth. 3rd edition. Oxford: Wiley Blackwell Publishers, to be published March 2012

Acknowledgement: I thank Prof. Gideon Holen of the Department of Pediatric Dentistry, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel, for providing some of the answers regarding the pediatric/endodontic treatment of traumatized teeth.