Management of a rare combination of avulsion and intrusive luxation: A case report.

In traumatic dental injury, concomitant occurrence of avulsion and intrusive luxation is exceptional. This is because the vectors of forces responsible for both avulsive and intrusive injuries are in different directions. The present case report reviews the management of a rare combination of avulsion in right maxillary lateral incisor (tooth #12) and intrusive luxation in right maxillary central incisor (tooth #11) in a 22-year-old Asian male. Clinical and radiographic evaluation was done at 12-month follow-up. Various treatment modalities and complications associated with both avulsion and intrusion are also discussed in the paper.

INTRODUCTION

Avulsions and intrusive luxations are the most difficult and notorious displacement injuries to manage and have the poorest prognosis of all dental traumas.[1] In avulsion, tooth is completely displaced out of its socket. It is caused by frontal impact with subsequent damage to the pulp as well as periodontal ligament and encompasses 0.5 to 16% of all dental traumatic injuries.[2] Avulsive injuries are more commonly observed in children between 7 and 9 years of age, in maxillary central incisors. In luxation injury, tooth is partially displaced out of its socket. Depending upon the extent of injury, it is classified as concussion, subluxation, extrusion, lateral luxation and intrusion. Intrusive luxation is the apical displacement of tooth into the alveolar bone. It comprises 1.9% of traumatic injuries involving permanent teeth.[3] The vectors of forces responsible for both avulsive and intrusive injuries are in different directions. Hence, the concoction occurrence of avulsion and intrusive luxation is exceptionally unusual. This case reports the management of a rare combination of avulsion in right maxillary lateral incisor (tooth #12) and intrusive luxation in right maxillary central incisor (tooth #11) in an adult patient.

CASE REPORT

A 22-year-old healthy Asian male was referred to the endodontic clinic by a general dentist. The patient presented to his dentist after a traumatic dental injury sustained while playing 20 minutes ago. Clinical examination revealed that #12 was avulsed and #11 was intrusively luxated. The avulsed tooth had been out of the mouth for 15 minutes in cold milk storage. Preoperative radiographs of #11 and #12 regions were taken. General dentist moped off the lacerated gingiva, rinsed the avulsed #12 in saline solution and repositioned it in its socket with no fixation [Figure 1a]. The case was opted for the referral immediately.

Figure 1

Pre-operative radiograph showing intruded #11 and replanted #12 (a). They were surgically re-positioned and stabilized using a non-rigid splinting to allow their physiological mobility (b). Additional stabilization of #11 was achieved by suturing (s)

Reports of the patient's first visit to the endodontic clinic related that the tooth #11 was intruded into the socket and tooth #12 was replanted. Tooth #21 showed an Ellis class II fracture (crown fracture involving enamel and dentine). The patient had labial gingival lacerations with respect to teeth #11 and #12. Tooth #11 was intruded approximately 3-4 mm {RCSE (Categories of the Royal College of Surgeons of England category) 2}. Replanted tooth #12 was not repositioned properly in its natural position in the socket. It was interfering in the occlusion and had a large talons cusp. The patient was explained regarding the treatment options. For tooth #11, considering the stage of root development (closed apex) and the amount of intrusion, immediate surgical reduction (active repositioning) was preferred. For tooth #12, in the view of appropriate pre-replantation management of avulsed tooth and socket, repositioning deep into the socket in its natural position was chosen. The risks, complications and possible outcomes of the treatment plan were explained and patient's written informed consent was obtained.

Local anesthesia (2% lidocaine with 1:1,00,000 epinephrine, LOX 2% Neon Lab, India) was deposited in the vicinity of the apices of #11 and #12. Re-positioning maneuvers for both the teeth was started by very gentle movements using dental extraction forceps. Teeth #11 and #12 were correctly re-positioned surgically such that they are out of any traumatic occlusion. A non-rigid (flexible) splint was placed with a flowable composite (Tetric N-flow, Ivoclar Vivadent, Schaan) and bondable reinforcement Ribbond (Ribbond Inc, Seattle, WA), incorporating both the intruded and avulsed teeth [Figure 1b]. Talons cusp present on #12 was reduced. Occlusal adjustment, antibiotic therapy, instructions about the importance of plaque control using chemical and mechanical methods were explained.

Patient was recalled after 10 days and the splint was removed. Root canal therapy was initiated in both #11 and #12. Endodontic access cavities were prepared using appropriate armamentarium (LA Access kit, Dentsply Maillefer, Tulsa, OK) under rubber dam isolation. Root canal preparation was carried by step back method using K files (Dentsply Maillefer, Ballaigues, Switzerland). Irrigation was performed using normal saline, 5.25 % sodium hypochlorite solution (Cmident, India) and 15% EDTA (Largal Ultra, Septodont, Saint Maur des Fosses, France); 2% chlorhexidine digluconate (R4, Septodont, Saint Maur des Fosses, France) was used as the final irrigant. The canals were dried with sterile paper points (Dentsply Maillefer, Tulsa, OK). Calcium hydroxide (Prime Dental Products Pvt Ltd, Mumbai, India) was used as an inter-appointment medicament. As per the recommendations by Andreasen et al.,[4] filling and condensation of calcium hydroxide was repeated 3 times, after which a small cotton pellet is placed. The access cavity was sealed temporarily with intermediate restorative material (IRM, Caulk Dentsply, Milford, DE). The patient was recalled after a month. The root canals were again irrigated with normal saline to remove the intracanal dressing of calcium hydroxide. Canals were dried. Obturation was completed by lateral compaction technique with the use of gutta-percha cones and epoxy resin-based root canal sealer (AH plus sealer, Dentsply Maillefer, Tulsa, OK). Tooth was restored using light cured composite resin (Z100; 3M Dental Products, St. Paul, MN, US). Final esthetic rehabilitation was carried out with the porcelain fused to metal crowns. Gingival margin of #11 was present more apically. Hence, pink porcelain was added in the gingival margin of the central incisor for the camouflage effect [Figure 2a]. Radiographic evaluation was done at 12- month follow-up [Figure 2b].

Figure 2

(a) Pink porcelain (pp) was added in the gingival margin o tooth #11 for the camouflage effect. (b) Clinical and radiographic examination done at 24 months follow-up

DISCUSSION

The contemporaneous occurrence of avulsion and intrusive luxation is exceptional. This is because the mechanisms of injuries associated with these two types of traumas are totally different; although the exact mechanisms are not described clearly. Avulsion occurs as a result of blunt, frontal impacts in young dentition where the periodontium is very resilient.[5] On the other hand, intrusive luxation occurs as a result of a direct impact on the incisal edge in an axial direction.[6] It may be associated with the crown or alveolar fracture. Luxation injuries frequently affect two or more teeth, while avulsions usually involve a single tooth.[2] The management strategy and factors affecting the treatment outcome for both these traumatic injuries are poles apart. So, the objective of this case report is to recount different factors that affect the treatment outcome and the several challenges that the clinician might have to deal with during the management of such injuries.

In replantation, the prognosis depends on the pre-replantation history, extra-alveolar duration (immediate or delayed replantation), type of storage medium, the condition of the avulsed tooth, the patient's age and stage of root development (open or close apex).[7] In the presented case, pre-replantation history taken from the dentist revealed that the tooth #12 surface was rinsed gently with a stream of saline from a syringe until visible contaminates were washed away. This was essential to prevent any inflammatory response. The alveolar socket was also rinsed with a flow of saline to remove the contaminated coagulum. However, tooth #12 was interfering in the occlusion. So, it was repositioned and large talons cusp was reduced to avoid any occlusal trauma.

The best transportation media for avulsed teeth include Viaspan, Hank's Balanced Salt Solution (HBSS, tissue culture medium), cool milk, saliva (buccal vestibule), physiologic saline, or water in the above order of preference.[89] Milk is considered to be the best transportation media because its osmolarity and pH is within the acceptable biological range.[10] It is very easily available at the trauma site. It can preserve the periodontal ligament cells up to six hours.[10] Cool milk will maintain the ability of PDL precursor cells to reproduce for almost twice as long as milk that is allowed to warm to room temperature.[11] Here, #12 was transferred to cool milk within the first 15 minutes. So there is high possibility of the cells in the PDL and cementum to survive and to play a role in reattachment of periodontal membrane. Postoperative complications that can be expected after replantation include surface resorption, replacement resorption or inflammatory root resorption.

Intrusive injury in permanent tooth is one of the most severe luxation injuries. Various complications like pulp necrosis, external root resorption and marginal bone loss may be seen in the intruded teeth.[12] Management of intrusion is influenced by the extent of injury and the stage of root development (immature or mature root).[13] The treatment modalities include passive repositioning that allow the immature tooth to re-erupt and active repositioning for permanent tooth that include orthodontic repositioning or immediate surgical reduction.[14] In teeth with severe intrusion (>7 mm), surgical repositioning will allow early start of root canal treatment. It results in more normal orientation of the periodontal fibers and consequently less replacement resorption as the fibers are under less tension with respect to the cementum and bone walls.[15] It is less time-consuming and requires fewer patient visits.[16] In surgical reduction, increased risk of marginal bone loss is correlated with the severity of the injury and not its technique. Orthodontic traction is suited for the management of moderately intruded (3-7 mm) teeth.[17]

Both the avulsed and intruded teeth were stabilized with the non-rigid (flexible) splint. It allowed the physiologic mobility that helped in the repair of the periodontal ligament.[11] Endodontic intervention was started after one week to facilitate the healing of periodontal ligament tissue.[18] Calcium hydroxide was used as an intracanal medicament to reduce the likelihood of root resorption that is associated with traumatic dental injuries.[19] This case report describes the challenges that the clinicians face in the management combined trauma of both avulsion and intrusion. In such multiple traumatic injuries, intervention should be based on the best scientific substantiation integrated with the clinician's skill and the values and expectations of patients. Therefore, the clinician has to recognize the problems and has to combine the guidelines meticulously to these situations. Clinicians may be “rusty” in both application of research-based information and management of such combined traumas because of its rarity. This case report clarifies the best research evidence and techniques for the management of avulsions and intrusions.