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Compendium
March 2016
Volume 37, Issue 3
Peer-Reviewed

At the initial appointment, the intraoral soft tissues were cleaned with saline and betadine. The patient was prescribed antibiotics, analgesics, and chlorhexidine mouthwash, and oral hygiene instructions were given and a soft diet was advised. Sutures were placed on the upper lip laceration.

Based on correlating clinical and radiographic findings, a complicated crown fracture involving pulp was diagnosed. The authors recommended root canal treatment of the intruded maxillary left central incisor, to be followed by orthodontic treatment. Informed consent from the patient was obtained after the treatment plan was explained.

Root Canal and Orthodontic Therapies

Root canal therapy was performed under rubber dam isolation using laterally condensed gutta-percha points (Tanari, Manacapuru, AM, Brazil, www.dentalcremer.com.br) and AH Plus® root canal sealer (DENTSPLY Maillefer, www.maillefer.com) in the maxillary left central incisor (Figure 4). The left central incisor was asymptomatic.

Orthodontic therapy was planned to reposition the luxated maxillary left central incisor after the endodontic treatment. It was performed using lingual splinting with traction on the intruded tooth for 6 weeks (Figure 5). The tooth was extruded approximately 0.5 mm every week and was thereby repositioned (Figure 6).

The maxillary left central incisor was further restored to improve esthetics using composite resin core build-up material (Vitremer™, 3M Dental Products, www.3m.com).

Prosthodontic Rehabilitation and Follow-up

After successful orthodontic treatment of the intruded tooth was completed, the tooth received prosthodontic rehabilitation. Following the post space preparation, a cast post was fabricated and cemented with resin-based cement (RelyX™, 3M Dental Products) for improved strength and stability (Figure 7). Finally, a porcelain-fused-to-metal crown was fabricated and placed on to the core and cemented (Figure 8).

The patient was recalled every 3 months for 1 year. Root canal treatment was performed on the maxillary left lateral incisor after it began showing signs of necrosis. A follow-up radiograph after 1 year showed no signs of progression of periapical pathosis (Figure 9).

Discussion

Intrusive luxations are serious traumatic injuries that often affect maxillary incisors, and the management of such cases can be complex. The treatment plan for these types of injuries depends heavily upon the severity of the injury.6 Treatment may range from a conservative approach, such as allowing for spontaneous re-eruption, to invasive methods involving immediate surgical repositioning. Spontaneous re-eruption is most common in intruded permanent incisors with immature root formation.3 According to the Royal College of Surgeons of England (RCSE), allowing for spontaneous re-eruption is especially the treatment of choice when the tooth apex is incomplete and/or the amount of intrusion is smaller than 3 mm, because the potential for eruption and pulpal or periodontal repair is high.7,8 This re-eruption is especially likely to occur when the dental pulp is vital; it rarely occurs when pulp necrosis is established.9

Thus, in the present case, due to the intrusion being more than 3 mm and because of pulpal necrosis, the multidisciplinary endodontic and orthodontic management was indicated. Orthodontic repositioning represents a biological procedure for teeth suffering these types of injury; moreover, an emergency endodontic treatment prevents inflammatory root resorption.8,10-12 It has been suggested that this alternative might allow for remodeling of bone and the periodontal apparatus. Successful treatment of cases using this technique has been reported in the literature.13 Andreasen and Andreasen have considered this option as the treatment of choice for most cases involving mature permanent teeth.13 The disadvantages of orthodontic extrusion have been reported as long treatment time and retention period, the need for strict patient compliance, and higher treatment costs.14-16

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