PEDIATRIC DENTISTRY/Copyright @1985 byThe American Academy of Pediatric Dentistry

Volume 7 Number 2

The changing role of endodontics and orthodontics in themanagement ~f traumatically intruded permanent incisors

Peter M. Spalding, DDS, MS Henry W. Fields,Dennis Torney, DDS, MS H. Bryan Cobb, DDS,

Abstract

Disagreement remains regarding the optimal treatmentfor intrusive luxation injuries to permanent teeth. Threeproblems often present themselves following intrusiveluxation: improper tooth position, pulpal necrosis, andinternal or external root resorption. In the recent past,the accepted treatment was to allow the permanent teethto reerupt spontaneously for 6-8 weeks. If this did notoccur, orthodontic traction was applied. The pulpal statusof the teeth was monitored and either calcium hydroxidetherapy or conventional endodontics was institutedfollowing pulpal necrosis depending on the maturity ofthe root end. Pulpectomy and a calcium hydroxide fillingmaterial were also the treatment of choice if there wasevidence of internal or external root resorption.

Recent evidence suggests that orthodontic repositioningshould commence as soon as possible following the traumaregardless of the stage of root development. Teeth withopen apices can be monitored. Those with closed apicesshould be opened, the pulp extirpated, and the canal filledwith a calcium hydroxide material. This will reduce thechance of root resorption and provide a period ofmonitoring prior to a definitive root canal filling. Twocases are presented that demonstrate these contrastingtreatment techniques and possible complications.

Effective endodontic and orthodontic manage-

ment of traumatic intrusive luxation of the permanentteeth in children arid adolescents continues to chal-lenge the dental profession. Management should in-clude an accurate diagnosis and treatment that willresult in the best prognosis. The purpose of this pa-per is to present two instances of intrusive luxation

Jr., DDS, MS, MSD

MS Johnny Johnson, DMD

and discuss the treatment and complications in viewof the changing and contrasting literature regardingthese injuries.

Literature Review

Traumatic intrusion is a form of luxation that dis-places the tooth in an apical direction. This injury ischaracterized by comminution of the alveolar socketand expansion of the alveolus to permit the new po-sition of the tooth. 1 Upon percussion, the intrudedtooth elicits a metallic sound similar to an ankylosedtooth -- distinguishing it from an unerupted tooth.The intrusion may be so severe that the affected toothappears to be missing upon clinical examination.Radiographic examination may reveal partial or totalobliteration of the periodontal ligament space.

Intrusive luxation of permanent teeth occurs lessfrequently than other types of luxation and is asso-ciated far more often with maxillary teeth than man-dibular teeth. 1,2 Although it is the less common formof luxation, it is reported to be the type which hasthe poorest prognosis. 2,3 However, few systematicstudies have appeared in the literature. A variety oftherapeutic measures have been reported, but the op-timal method of returning the tooth to its normal po-sition remains to be determined.4,~

In the past, surgical repositioning and splinting havebeen recommended. This type of repositioning hasserious pulpal and periodontal consequences. A sig-nificantly higher percentage of marginal bone loss,ankylosis, and pulpal inflammatory response havebeen demonstrated following surgical repositioningof intruded teeth in comparison to permitting spon-taneous reeruption or orthodontic repositioning,s

It has been suggested that intruded permanent teeth

104 TRAUMATICALLY INTRUDIED INCISORS: Spalding et al.

with incomplete root formation be permitted to re-erupt spontaneously since there is significant erup-tion potential of such teeth.4 If no eruption occurredwithin 2 months or root formation was complete, or-thodontic repositioning was advised.6 7

Although Andreasen conducted a retrospective in-vestigation of 189 luxated permanent teeth and foundthat the 23 intruded teeth ultimately demonstrated96% incidence of pulpal necrosis, pulpectomy wasnot recommended initially unless pulpal necrosis wasdiagnosed.1 In teeth with complete root formation,pulpal necrosis was treated with conventional en-dodontics. In those with incomplete root formation,pulpal necrosis was treated with either pulpotomy orpulp extirpation followed by procedures to close theopen apex.5

Another complication of intrusive luxation is rootresorption. In Andreasen's study, 52% of the in-truded teeth were affected by either external replace-ment or inflammatory resorption.1 External rootresorption was treated by either pulpectomy and acalcium hydroxide fill or conventional endodontics.

A final problem frequently associated with trau-matically intruded permanent teeth is loss of mar-ginal bone support. Andreasen found this complicationwith 48% of the intruded teeth and attributed such ahigh incidence to the severity of the periodontal in-jury and the delay in treatment.1

It now appears that the appropriate treatment forintruded teeth with or without complete root for-mation is immediate application of orthodontic forcesto reposition the teeth in 3-4 weeks in order to avoidankylosis and permit monitoring or early access forendodontic treatment.5-8 For teeth with complete ap-ices, extirpation of the pulp followed by a calciumhydroxide fill is indicated within 14 days of the in-jury. This has been advised due to the certainty of

Fie 2. Patient 1, initialperiapical radiograph ofintruded permanentmaxillary incisors. Notethe incomplete rootformation and the ap-parent absence of den-tal or alveolar fractures.

Fie 1. Patient 1 (initial visit), showing 7 mm intrusion of thepermanent maxillary central incisors and 2 mm intrusion ofthe permanent maxillary right lateral incisor.

pulpal necrosis and the need to prevent root resorp-tion. Teeth with immature root formation can be ob-served for pulp necrosis and root resorption — therapycan be instituted immediately if necessary.

Turley et al.8 conducted an investigation studyingspontaneous reeruption and orthodontic reposition-ing as treatment options for managing intrusive lux-ation of permanent teeth in dogs. They traumaticallyintruded first premolars with completely formed ap-ices, subjected half of these teeth to orthodontic ex-trusive forces, and allowed the other half to eruptspontaneously. In their study, the more severely in-truded teeth exhibited ankylosis and failed to eruptor respond to orthodontic extrusion. The less se-verely intruded teeth did not become ankylosed, butdemonstrated some spontaneous eruption as well asextrusion from orthodontic forces.

In a later study, Turley et al.4 found that severelyintruded (5-6 mm) teeth could be extruded ortho-dontically if they were luxated following the trauma.Their conclusions suggest that the severity of thetraumatic intrusion and the amount of mobility pres-ent are important factors affecting the prognosis forspontaneous reeruption or orthodontic extrusion.

Clinical Reports

Two injuries are reported that demonstrate boththe old and new treatment options recommended forintrusive luxation: allowing reeruption, and imme-diate orthodontic repositioning (as well as differenttiming for pulpal extirpation).

The first report involved a 6-year, 11-month-old blackfemale injured in a fall on stairs at school. The patientwas transported immediately to a hospital emergencyroom where her neurologic status was evaluated. No

PEDIATRIC DENTISTRY: June 1985/Vol. 7 No. 2 105

neurologic problems were found, and subsequentlyshe was referred to the pediatric dentistry clinic. Themedical history was unremarkable and immuniza-tions were current.

Extraoral examination was unremarkable except fora laceration on the lower lip. Intraoral examinationrevealed 7 mm intrusive luxations of the maxillarycentral incisors and a 2 mm intrusion of the maxillaryright lateral incisor (Fig 1). The 3 intruded teeth wereseated firmly in alveolar bone with no clinical mobil-ity. The mandibular central incisors demonstratedslight mobility without apparent displacement. Therewas no clinical evidence of traumatic involvement ofany other teeth or alveolar structures.

Radiographs revealed no apparent fractures of thedentition or surrounding alveolar bone. The radio-graphs confirmed the clinical impression of intrusiveluxation and revealed that these teeth had incompleteroot formation (approximately 7/8 complete) with openapices (Fig 2).

Treatment at the initial visit consisted of irrigationand suturing of the lower lip laceration with the aidof local anesthesia. The teeth were not repositionedor splinted at that time, but were monitored closelyfor evidence of reeruption and possible pathologicpulpal response.

At 1-week follow up, there was no clinical evidenceof reeruption by measurement to adjacent uninjuredteeth. This method, in addition to visual inspection,was used at subsequent appointments for reevalua-tion. Subsequent weekly visits revealed no reerup-tion of the intruded incisors or evidence of pulpalpathology.

Seven weeks following the trauma, a decision wasmade to reposition the intruded teeth orthodonti-cally. An appliance was constructed that included aheavy, round wire soldered to bands placed on the

Fie 3. Patient 1, post-operat ive periapicalradiograph demon-strating final obtura-tion of the ortho-dontically reposi-tioned incisors 10months posttrauma.Note the extrusion ofcanal filling materialbeyond the apex of theleft central incisor.

primary maxillary second molars and canines, bondedattachments on the intruded teeth, and elastic trac-tion. This appliance delivered an extrusive force ofapproximately 100 gm to each incisor.

At the appliance insertion appointment, a periap-ical radiograph revealed external root resorption in-volving the maxillary central incisors. In order toprevent progression of the pathologic resorption andpermit root end closure, calcium hydroxide pulpec-tomies were planned. Since the teeth could not beisolated for endodontic treatment due to their in-truded position, a decision was made to wait 1 weekwith the expectation that orthodontic movement wouldprovide enough lingual access to perform the calciumhydroxide pulpectomies.

One week following placement of the appliance (9weeks posttrauma), approximately 1 mm of extrusiveorthodontic movement had occurred. Nevertheless,the movement was still insufficient for adequate en-dodontic access. Since it was believed that endodon-tic treatment was needed immediately, a localgingivectomy was performed lingual to the intrudedteeth to provide sufficient access for the calcium hy-droxide pulpectomies. A rubber dam then was placed,access to the pulps was obtained, necrotic pulp tissuewas extirpated, and calcium hydroxide was packedin the instrumented canals to within 1 mm of theapices.

Twelve weeks following the original trauma, aperiapical radiograph revealed external root resorp-tion involving the intruded maxillary right lateral in-cisor. The tooth was opened, necrotic pulp tissue wasextirpated, and calcium hydroxide was placed to within1 mm of the tooth apex.

Two weeks later, less than 6 weeks following theinitial appliance placement, orthodontic extrusion wascomplete and the appliance was removed. The po-sition of the teeth was retained with a .0195 twistedmultistrand wire bonded with resin on the labial sur-face of the maxillary teeth for 3 months.

Seven weeks following the initial endodontic treat-ment (4 months posttrauma), the calcium hydroxidewas removed from the 3 incisors and the pulp canalswere refilled with fresh calcium hydroxide. A peri-apical radiograph revealed no apparent progressionof the external root resorption, but the teeth weremonitored monthly with radiographs.

Eleven weeks following placement of the retentionappliance, the retention was removed and the 3 in-cisors again were refilled with fresh calcium hydrox-ide. A study model of the maxillary dentition wasobtained as a reference to assess further tooth move-ment.

Ten months posttrauma, the calcium hydroxide wasremoved and positive apical stops were apparent onall 3 teeth. Final obturation was achieved with lateral

106 TRAUMATICALLY INTRUDED INCISORS: Spalding et al.

condensation of gutta percha. The postoperativeperiapical radiograph of the left central incisor re-vealed that root canal sealer had been extruded be-yond the apex (Fig 3).

A periapical radiograph was obtained 7 weeks fol-lowing the final obturation procedures (1 year post-trauma). The film indicated no further pathology. Theteeth had remained in position, providing adequatefunction and an esthetic appearance (Fig 4).

Follow-up periapical radiographs obtained 6 years,6 months posttrauma revealed the incisors were freeof pathology and no further resorption had occurred(Fig 5). The teeth were in the appropriate positionsand demonstrated normal mobility with no sensitiv-ity to percussion (Fig 6).

The second history involved a 10-year, 1-month-

FIG 4. Patient 1, postoperative intraoral condition of the or-thodontically repositioned and endodontically treated inci-sors 12 months posttrauma.

old black female who fell while roller skating. Thepatient reported to a local emergency room where shewas evaluated and dismissed with antibiotics and painmedications. Two days later the patient presented tothe pediatric dentistry clinic in no apparent distressand with no evidence of neurologic problems. Ex-traoral examination was unremarkable, with the ex-ception of facial abrasions and an edematous upperlip. Intraoral examination revealed edematous softtissue facial and lingual to the maxillary incisors. Themaxillary central incisors were intruded 8 mm. Themaxillary right central and lateral incisors had mesialincisal Ellis Class I fractures while the maxillary leftcentral incisor had a mesial incisal Ellis Class II frac-ture.10 All teeth exhibited limited mobility (Fig 7).

A panorex radiograph revealed no mandibularfractures and the maxillary periapical radiographsconfirmed the incisal fractures, but were negative forroot or alveolar fractures. Root development on allmaxillary incisors was complete (Fig 8).

Orthodontic attachments were placed on anterior

Fie 5. Patient 1, follow-up radiographs illustrating arrestedroot resorption and absence of pathology 6 years, 6 monthsposttrauma.

FIG 6. Patient 1, follow-up intraoral condition of the patient 6years, 6 months posttrauma.

and posterior teeth and an archwire and elastic trac-tion were used to reposition the central incisors asrapidly as possible. Since the apices were closed inthese teeth, they were to be opened, the pulp extir-pated, and a calcium hydroxide material placed whenaccess was favorable.

Due to poor patient compliance with appoint-ments, extrusion was continued over a 4-month pe-riod before access was possible. At that time, thecentral incisors also were evaluated clinically andradiographically. The right central incisor demon-strated external root resorption and the left centralincisor had a vertical crown fracture extending to themidroot region and external root resorption. The rightcentral incisor was opened, the necrotic pulp extir-pated, and a calcium hydroxide material placed. Theleft central incisor was extracted due to the hopelessprognosis (Figs 9, 10).

PEDIATRIC DENTISTRY: June 1985/Vol. 7 No. 2 107

Fie 7. Patient 2, initial condition of traumatically intruded per-manent central incisors at presentation for treatment 48 hrposttrauma.

Fie 8. Patient 2, initial periapical radiographs of intruded per-manent incisors 48 hr posttrauma. Note the apparent absenceof root or alveolar fractures.

Clinical and radiographic observation at 6 weeksrevealed that the resorption was controlled, the teethwere asymptomatic, and reasonable vertical tooth po-sition had been achieved (Figs 11, 12).

DiscussionAppropriate treatment for traumatic dental intru-

sion has been controversial in the dental profession.The current state of knowledge regarding treatmentis based largely on empirical clinical experience ratherthan scientific evidence. Investigation is needed toimprove the prognosis of these cases.

The choice of treatment in these cases was madewith careful consideration of the specific type of in-jury. Waiting for spontaneous reeruption, oncethought to be the best choice for teeth with intrusiveluxation and incomplete root formation, was at-

tempted in the first patient. The complications en-countered in this case graphically point to theshortcomings of this treatment philosophy. If inad-equate eruption, pulpal necrosis, or internal or ex-ternal root resorption occur, intruded teeth will requireadjunctive orthodontic repositioning. Because of a lackof immediate orthodontic repositioning of the teethin the first patient, a gingivectomy and delayed place-ment of calcium hydroxide in the root canals wererequired. In the second patient, the immediate or-thodontic repositioning provided access to the lingualsurface for calcium hydroxide treatment and helpedto provide the definitive diagnosis on 1 of the teethsince a direct visual examination was made possible.Unfortunately, patient compliance problems delayedroot canal treatment with calcium hydroxide and rootresorption began.

Recent evidence indicates that failure to begin or-thodontic extrusion immediately following severe in-trusion of permanent teeth with fully formed apicesmay result in ankylosis, precluding orthodontic re-positioning.8 Regardless of the status of the root de-velopment, immediate orthodontic repositioningappears to be the treatment of choice to improve ac-cess for endodontic treatment deemed necessary,speed placement of calcium hydroxide, and reducemarginal bone loss. This type of treatment requirescareful assessment of the orthodontic mechanics inorder not to impinge on the soft tissue and maintainlight continuous forces. Excellent patient complianceis necessary to maintain good oral hygiene and meetappointment schedules.

The loss of pulp vitality is another common findingwith traumatically luxated teeth.1 The direction of theforce associated with intrusive luxation often crushesthe apical blood vessels and periodontal ligament ofthe affected tooth. Complications manifested by thetraumatized tissue such as external or internal rootresorption are an indication of pulpal and periodontalpathology and the teeth must be treated endodonti-cally. In both patients presented here, pulpal necrosisfollowed the intrusive injury as is seen in most teethwith nearly complete or complete root development.

The prevalence of such pathology is so high in in-stances of intruded teeth with complete root forma-tion that pulpal extirpation and placement of a calciumhydroxide material should occur as soon as possibleafter the injury. In teeth with open apices, carefulobservation is necessary so that necrotic pulp tissuecan be removed as soon as it is diagnosed. One shouldbe aware that pulpal survival following traumatic in-trusion is extremely rare even if root formation is in-complete. If pulp tissue is extirpated, all degeneratingtissue must be removed before obturation with cal-cium hydroxide, but the level to which this will beaccomplished depends on the individual tooth and

108 TRAUMATICALLY INTRUDED INCISORS: Spalding et al.

FIG 9. Patient 2, intraoral condition revealing ver-tical crown fracture extending onto root surface 4months posttrauma.

FIG 10. Patient 2, periapical radiograph illustratingexternal resorption on the apical portions of themaxillary central incisors. Note that the crown androot fracture of the maxillary left central incisor isdifficult to detect 4 months posttrauma.

FIG 11. Patient 2, intraoral view of the orthodonticallyrepositioned tooth 5 months, 2 weeks posttrauma.

FIG 12. Patient 2, radiograph of the remaining centralincisor following calcium hydroxide fill. Note that theroot resorption has not progressed.

the state of its pathology. It is most desirable to main-tain some vital healthy radicular pulp tissue in orderto allow apical closure to occur and to allow contin-ued root development. A better crown to root ratio,improved root strength, and a more desirable situa-tion for endodontic therapy will result. With com-plete pulpal necrosis, apexification is indicated in orderto generate a positive apical stop, facilitating root canaltherapy.11

All 5 retained teeth in these two patients developedroot resorption. Complete removal of degenerativetissue and oblituration of the root canal with calciumhydroxide in teeth with complete root developmentwill help reduce the onset of external or internal rootresorption if instituted early enough. Calcium hy-droxide treatment limited the root resorption in allintruded teeth reported here. Calcium hydroxide canbe placed in teeth with incomplete root formation ifroot resorption is noted. This usually stops root re-sorption and eliminates periodontal ligament pathol-ogy which may provide the additional benefit ofmaintaining the integrity of Hertwig's root sheath andallowing continued root development. If root closureis achieved, surgical endodontic treatment can beeliminated in a large number of teeth.

If contemporary recommendations for reposition-ing teeth orthodontically are followed, root resorp-tion may be a problem. When the injury has been

minor or moderate in severity, root resorption prob-ably will not result with orthodontic movement.12

However, teeth with a history of severe trauma orresorption prior to orthodontic treatment may be moreprone to root resorption.12'13

ConclusionsThese clinical reports illustrate the complicating

factors associated with intrusively luxated teeth. Thenecessity for coordination of orthodontic and endo-dontic treatment has been reported. The treatmentincludes immediate orthodontic repositioning of allintruded teeth and the indicated endodontic treat-ment for pulpal necrosis to prevent or arrest root re-sorption. These recommendations are based on thebest available evidence, but should be evaluated con-stantly in the face of new reports from controlledstudies.

The authors acknowledge the assistance of Ms. Jane Womble andMs. Carolyn Gravely in manuscript preparation.

Dr. Spalding is an assistant professor, orthodontics, School of Den-tistry, the University of Michigan, Ann Arbor, MI 48109-1078. Dr.Fields is an associate professor, pedodontics and orthodontics; Dr.Torney is an associate professor, endodontics; Dr. Cobb is a clinicalinstructor, pedodontics; and Dr. Johnson is a graduate student,pedodontics, University of North Carolina. Reprint requests shouldbe sent to Dr. Spalding.

PEDIATRIC DENTISTRY: June 1985/Vol. 7 No. 2 109

1. Andreasen JO: Luxation of permanent teeth due to trauma:a clinical and radiographic follow-up study of 189 injuredteeth. Scand J Dent R~s 78:273-86, 1970.

2. Andreasen JO: Etiolog 7 and pathogenesis of traumatic dentalinjuries: a clinical study of 1298 cases. Scand J Dent Res 78:329-42, 1970.

3. Skieller V: The prognosis for young teeth loosened after.me-chanical injuries. Acta Odontol Scand 18:171-81, 1960.

4. Bruszt P: Secondary eruption of teeth intruded into the max-illa by a blow. Oral Surg 11:146-49, 1958.

5. Andreasen JO: Traumatic Injuries of the Teeth. Philadelphia;WB Saunders Co, 1981 pp 164-66.

6. Cohen S, Burns R: Pathways of the Pulp. St. Louis: CV MosbyCo, 1976 p 405.

7. Taintor JF, Bonness PW, Biesterfield RD: The intruded tooth.Dent Survey 55:30-34, 1977.

8. Turley PK, Joiner MW, Hellstrom S: The effect of orthodontic

extrusion on traumatically intruded teeth. Am J Orthod 85:47-56, 1984.

9. Turley PK, Crawford LB, Carrington KW: Factors influencingthe management of traumatically intruded teeth. IADR Pro-gram and Abstracts, no 240, 1984.

10. Ellis R, Davey K: The Classification and Treatment of Injuriesto the Teeth of Children, 5th ed. Chicago: Year Book MedicalPublishers, lnc, 1970 p 182.

11. Frank AL: Therapy for the divergent pulpless tooth by con-tinued apical formation. JADA 72:87-93, 1966.

12. Malmgren O, Goldson L, Hill C, Orwin A, Petrini L, Lund-berg M: Root resorption after orthodontic treatment of trau-matized teeth. Am J Orthod 82:487-91, 1982.

13. Hines FB: A radiographic evaluation of the response of pre-viously avulsed teeth and partially avulsed teeth to ortho-dontic movement. Am J Orthod 75:1-19, 1979.

Quotable quote: smokeless tobaccoThis paper compared the use of smokeless tobacco and its effects in rural and urban teenagers. A random

sample of 445 subjects from rural Colorado were examined: 82.9% of the total sample were Caucasian, and94.6% of those who used smokeless tobacco were Caucasian. This percentage supports the findings of anearlier urban st~:dy that the habit is predominately one of male Caucasians. The average age of the users

was 16.7 years, slightly older than in the urban study.Of the rural users, 62.5% had lesions of the oral tissues, compared with a 48.7% lesion incidence in urban

users. In both studies, those subjects with lesions had longer daily contact with smokeless tobacco, as wellas a longer history of use than those without lesions.

Poulson TO, Lindenmuth, JE Greer Jr RO:A comparison of the use of smokeless

tobacco in rural and urban teenagers. CASept/Oct, 1984.

TRAUMATICALLY INTRUDED INCISORS: Spalding et al.