Article Type : Case Report
Authors : Shunmugavelu K
Keywords : Trauma; Dental; Eruption; Deciduous; Luxation; Intrusion
Luxation
injuries are most seen in deciduous dentition, resulting in damage to pulp and
periodontium. The challenging task of managing these types of injuries depend
on the clinical and radiographical follow up. In this case report, intrusive
luxation of deciduous maxillary right central incisor in a 2-year-old female
due to accidental fall has been highlighted. Spontaneous eruption was observed
after 6 months of injury.
Dental trauma involves 1/3 rd
of the pediatric population pertaining to deciduous dentition. Etiology
includes decreased motor coordination and deficiency in risk evaluation. Main
causative factor for intrusive luxation is the resilience nature of alveolar
bone. Intrusive luxation is defined as tooth displacement in an axial direction
into the alveolar bone [1]. It is classified as complete due to
enveloping nature of surrounding tissues and partial when incisal border of
crown is seen. Age involvement begins from first year of life, toddler,
crawling, walking, and exploring stages. Most susceptible age group is between
1 to 3 years, due to complete formation of roots of deciduous incisors.
Frequency of deciduous maxillary incisors account between 63% and 92% [2,3]. In
this scientific article a case of intrusive luxation of deciduous maxillary
right central incisor in a 2-year-old female due to accidental fall has been
reported, managed conservatively, through eruption.
A 2-year-old female patient was referred to the Department of Pediatric Dentistry, one day after a fall on the floor. Clinical examination revealed intrusion of right maxillary deciduous central incisor, bleeding on pressure and lip contusion. General examination and neurological status were within normal limits. Orthopantomogram and intraoral periapical radiograph revealed foreshortening of the image thereby displacement of deciduous tooth away from the permanent tooth germ (Figures 1 and 2) To minimize the spread of infection, antibiotic therapy such as amoxycillin and analgesic such as paracetamol was started for 3 days.
Figure 1:
Orthopantomographic view depicting intrusively.
Oral hygiene instructions such as soft tooth brushing, avoidance of oral habits such as thumb or digit sucking, soft diet, twice a week review for first 2 weeks and then every month till eruption. Around 6 months, 90% of the tooth has erupted (Figure 3). Patient was asymptomatic.
Figure 2: Intraoral periapical radiographic view depicting in incisor.
Figure 3: Clinical view
depicting reeruption.
Etiology links to fall
involving baby carriages, hard objects, staircases, outdoor games, and child
abuse. Mineralization and increased rigidity of alveolar bone increases the
possibility of crown and root fracture in higher age group. Elasticity of
alveolar bone occurs due to large marrow spaces resulting in displacement.
Decreased resistance to intrusive luxation occurs in case of short roots,
resorbing roots and high crown root ratio [4]. Luxation injuries due
to objects in the child’s mouth during fall might result in disturbance to the
permanent tooth germ. Due to labial curvature of root, intrusion occurs in case
of impact with axial component. Apex penetrates the labial plate leading to
axial and labial displacement. Rupture of gingival fibers of the periodontal
ligament palatially whereas compression of periodontal ligament occurs
labially. Invasion and infection of the periodontal ligament occurs along the
root surface due to detachment of gingival fibers. Oedema and disorganization
of odontoblastic layer followed by nuclear pyknosis of pulp cells,
hyalinization and diffuse calcifications occurs after trauma [5,6].
Diphtheria-pertussis-tetanus vaccine is usually administered at 18 months of
age. In case of trauma, a booster dose is needed if immunization has not been
done within 5 years. In behavioral aspect, decreased ability to communicate is
seen in children younger than 3 years of age. Clinical examination includes
central nervous system assessment such as nausea, vomiting, seizures, cyanosis,
loss of consciousness, abnormal respiration, unsteadiness, rhinorrhea, slurred
speech, otorrhea and eye movements. Extraoral examination includes head, neck,
mandibular function, temporomandibular joint, facial asymmetry, lips, overlying
skin, and nasal region. Intraoral examination includes inner aspect of lips,
oral mucosa, tongue, teeth, gingiva, frenum, sulcus and vestibule assessment.
Contusions of lower lip and chin are most found in intrusion. Clinically,
complete intrusion of tooth might appear invisible due to blood clot and
edematous gingiva around the incisal edges [7]. Classification of intrusion is
as follows,
Grade I – more than 50% of
tooth structure visible in mild partial intrusion.
Grade II – less than 50% of
tooth structure visible in moderate partial intrusion
Grade III – Severe or complete
intrusion
In case of alveolar bone
fracture during intrusion, the involved teeth and the bone will move as a
single unit. Radiographically, if the image of the deciduous incisor is
foreshortened, then it indicates that the involved tooth is away from the
permanent tooth germ whereas if the images is elongated then it indicates that
the involved tooth is into the follicle of the permanent tooth. Management
depends on the following factors,
1) Degree of intrusion – In
mild cases, eruption is expected whereas extraction plays a sole role if there
is infection or necrosis in moderate or severe cases. Ankylosis occurs when
eruption does not occur in 4-8 weeks. Factors such as thumb or digit sucking
act as hindrance for eruption.
2) Direction of intrusion -
Labial curvature of deciduous maxillary incisor helps in movement away from the
underlying tooth germ. Factors to be observed are periapical inflammation, pulp
necrosis, ankylosis, external root resorption and pulp canal obliteration.
3) Alveolar bone fracture –
perforation of buccal cortical plate during intrusion plays an important role
in extraction of the offending tooth. 90% of intruded teeth will erupt
spontaneously whereas only affected tooth with severely damaged periodontal
ligament might result in ankylosis. Prognosis depends on the time lapse between
the event and treatment.
Follow-up protocol is as
follows,
1)
Clinical
examination in first week
2)
1+
radiographical examination in 3-4 weeks
3)
1 alone
in 6-8 weeks
4)
2 alone
in 6 months
5)
2 alone
in 1 year (till exfoliation and eruption of permanent tooth)
The most widely
accepted protocol for management of intrusive luxation of deciduous tooth in
case of palatal movement is wait and watch for eruption. In case of
inflammation, fever, malaise, pain, pulpal necrosis and pathological root
resorption, the involved tooth must be extracted. Complications of anterior
tooth loss includes difficulty in speech, development of tongue habits and an
aesthetic setback [8-10]. The affected tooth was also palatially
away from the permanent tooth germ radiographically. Parents were also educated
to observe for oral habits so that it may not act as a hindrance to erupting
tooth. Periodical clinical and radiographical reviews played an important role
in wait and watch policy. Finally, eruption of the intrusively luxated right
maxillary deciduous incisor occurred without any complications.
The treatment protocol
depends on the direction and degree of intrusion. Maximum cooperation from the
patient side can be obtained by following tell show do technique, short
appointments, and presence of parents in the dental office. Clinical and
radiographical evaluation should be done simultaneously to achieve successful
outcome leading to restoration of aesthetics, function, and appearance.