Journal of Dentistry Indonesia
Volume 28 Article 10
Number 3 December
12-31-2021
Management of Severe Dento-Alveolar Traumatic Injuries in a
9-Year old Boy: A Case Report
Elnaz Mousavi
Department of Endodontics, Guilan University of Medical Sciences, Rasht, IR Iran,
[email protected]Masoomeh Khoshdel
Postgraduate Program of Pediatric Dentistry, Student Research Committee, Faculty of Dentistry, Qazvin
University of Medical Sciences, Qazvin, IR Iran, [email protected]
Hamidreza Sharifiyan
Private Practice, Qazvin, Iran, [email protected]
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Recommended Citation
Mousavi, E., Khoshdel, M., & Sharifiyan, H. Management of Severe Dento-Alveolar Traumatic Injuries in a
9-Year old Boy: A Case Report. J Dent Indones. 2021;28(3): 192-197
This Case Report is brought to you for free and open access by the Faculty of Dentistry at UI Scholars Hub. It has
been accepted for inclusion in Journal of Dentistry Indonesia by an authorized editor of UI Scholars Hub.
Journal of Dentistry Indonesia 2021, Vol. 28, No. 3, 192-197
doi: 10.14693/jdi.v28i3.1257
CASE REPORT
Management of Severe Dento-Alveolar Traumatic Injuries in a 9-Year old
Boy: A Case Report
Elnaz Mousavi1, Masoomeh Khoshdel2, Hamidreza Sharifiyan3
1
Department of Endodontics, Guilan University of Medical Sciences, Rasht, IR Iran
2
Postgraduate Program in Pediatric Dentistry, Faculty of Dentistry, Qazvin University of Medical Sciences, Qazvin,
IR Iran
3
Private Practice, “Gazvin”, IR Iran
Correspondence e-mail to:
[email protected] ABSTRACT
Dentoalveolar traumas can lead to various injuries that may result in tooth loss. A suitable treatment plan and
appropriate interventions should be performed to maintain the dental function and aesthetics, especially for the
anterior teeth. Objective: To report the interventions performed on dentoalveolar trauma on a 9-years old male
patient who presented with gingival immersion of the right maxillary central incisor and missing a tooth due to
a falling accident. Case Report: The patient had multiple traumatic injuries. The medical and dental history was
taken, and the clinical and radiologic examinations were performed. The patient underwent surgical intervention and
splinting to take the intruded tooth back into its normal place. Moreover, the teeth with lateral luxation underwent
apexification and composite filling. Also, endodontic treatment was performed on the coronal segment of the
tooth with root fractures. The patient underwent clinical and radiographic follow-up for 24 months to assure the
treatment efficiency and prevent further complications. Conclusion: It was shown that the interventions performed
could preserve the function and aesthetics of the patient’s teeth, which can directly impact his quality of life and
emotional state in adolescence.
Key words: tooth avulsion, tooth luxation, intrusive luxation, pulp necrosis
How to cite this article: Mousavi E, Khoshdel M, Sharifiyan H. Management of severe dento-alveolar trau-
matic injuries in 9-years old boy: A case report. J Dent Indones. 2021;28(3):192-197
INTRODUCTION
Traumatic dental injuries (TDI) are common throughout Among all types of dental injuries, avulsion and
the world. A recent report revealed that more than one intrusion are the most severe cases. These injuries
billion living people have at least one experience of may have unfavorable outcomes, leading to multiple
traumatic dental injuries.1 Dentoalveolar traumatic sequelae, such as pulpal necrosis, external root
accidents comprise most of the encountered cases of resorption, and replacement resorption. Other severe
dental emergencies. These injuries are classified into forms of traumatic dentoalveolar injuries are lateral
four types: gingival or oral mucosal injuries (soft tissue luxation and root fractures. These types of injuries
injuries), injuries to the supporting bone, periodontal have various outcomes. The condition of dentin-pulp
injuries, and injuries to hard dental tissues and dental complex, cementum, alveolar bone, and periodontal
pulp. Complete cure is not possible for some of these ligament determine the method and design of the
injuries. Due to the complicated management, the treatment plan, therapeutic effectiveness, and
prognosis of these injuries can be unpredictable. The outcome.4, 5
treatment course can be difficult and costly for the
patient because these problems should be followed and Traumatic injuries should be treated as soon as possible
managed for a long time to achieve the best outcome. to reduce unfavorable complications, preferably at the
The outcome of these injuries can affect the dental moment in avulsion cases and within the first hour in
function and aesthetics, as well as the patient’s quality other injuries.6 Most of these traumas are in pediatric
of life.2, 3 patients and usually happen in schools. Treatment for
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younger patients differs from those of adolescents. A of tooth loss were explained to the parents; however,
suitable treatment plan can help in preserving the tooth they did not intend to accept any suggested treatments
for a quite favorable time.7 for space maintenance.
The main goal of the present report was to describe a The first tooth to be treated in the treatment plan was
case of delayed multiple dentoalveolar traumas who the permanent maxillary right central incisor (no. 8),
was a 9-years old boy with dental avulsion, intrusion, immersed in the gingiva. The treatment for this tooth
lateral luxation, and root fracture due to a falling was initiated in the first treatment session because
accident. it needed immediate intervention. It was already
intruded more than 7 mm; thus, surgical extrusion
was considered. Local anesthesia was performed using
CASE REPORT infiltration injection with 0.6 ml of 2% lidocaine +
1/80000 epinephrine. Then, the tooth was extruded
A 9-year-old boy was presented to the clinic of the using 150A Cryer forceps (Hu-Friedy, Chicago, IL,
School of Dentistry of the Guilan University of USA) until reaching the incisal edge of the adjacent
Medical Sciences with the chief complaint of gingival tooth (Figure 2). Peri-apical radiography was taken
immersions of the maxillary incisors and missing a to ensure the intactness of the root (Figure 3A). Then,
tooth due to a falling accident in school three days semi-rigid bilateral splinting was performed using the
ago (Figure 1A). No notable past medical and dental Filtek™ resin composite (Filtek™ P90 Silorane shade
history was reported. The patient’s general appearance A2; 3M ESPE, St Paul, MN, USA), G-Premium bond
was normal, with no external lacerations. Moreover, (GC, Tokyo, Japan) as the bonding agent, and a 0.019 x
the patient was vaccinated against tetanus according 0.025 stainless steel orthodontic wire (3M Unitek). The
to the national guidelines. splinting was performed from the permanent maxillary
right first molar to the permanent maxillary left first
The patient underwent full extra-oral to intraoral molar (Figure 3B). Since the tooth was mobile and the
examinations to rule out other major injuries. There isolation was not possible, endodontic treatment was
was no extra-oral injury. Intraoral examinations postponed to the next session, and the patient was asked
revealed no problem in the tongue, palate, and mouth to have a diet containing soft food.
floor. Complete dental examinations, vitality tests
The second treatment session was 4 weeks later, in
(electric pulp test, heat, cold, percussion, mobility,
which the mobility and vitality of tooth no. 8 was
and palpation tests), and radiographs (peri-apical
evaluated. The tooth had gained the desirable stability.
and orthopantomograph) were performed, and the
The splint was removed. Moreover, the permanent
related results are presented in Table 1. Based on the
maxillary left central incisor had been diagnosed
examination results and radiographs (Figure 1B), a
necrosis in the first treatment session. Thus, both
differential diagnosis was made (Table 1).
permanent maxillary central incisors (no. 8 and 9)
In the first treatment session, the treatment course underwent endodontic treatment. After the local
was explained to the patient’s parents. Moreover, the anesthesia, the rubbers dam and clamp (Hu-Friedy,
parents gave informed consent for treatment initiation. Chicago, IL, USA) were placed. An access cavity was
Oral amoxicillin (250 mg TDS) and chlorhexidine prepared for both teeth (no. 8 and 9). Due to the presence
mouthwash were prescribed for the patient to prevent of open apices, the working length was determined
infection. using radiography. The initial file was a #55 k-file
(Maillefer SA, Ballaigues, Switzerland). Irrigation was
Preliminary treatment plan for maxillary incisors was performed using 0.5% sodium hypochlorite and 5.25%
considered as follows: chlorhexidine solutions, and filing was performed
• Maxillary right central incisor: surgical extrusion, gently to prevent dentinal damage. Canals were filled
splinting for 4 weeks, calcium hydroxide therapy with calcium hydroxide paste (Masterdent, NY, USA),
for 7-10 days, apexification, composite filling, and and a temporary coronal filling was placed using the
follow-up. packable Fuji IX (GC, Europe).
• Maxillary left central incisor: splinting, calcium
hydroxide therapy for 7-10 days, apexification, The third treatment session was 2 weeks later, in which
composite filling, and follow-up. radiography was performed to evaluate the condition of
• Maxillary left lateral incisor: splinting and follow- the root canals, of teeth no. 8 and 9. Local anesthesia
up. and isolation were performed. Then, calcium hydroxide
• Maxillary right lateral incisor: space maintenance was removed using irrigation, canals were dried using
until prosthetic rehabilitation. paper points, and a 4-mm apical barrier with Mineral
Tri-oxide Aggregate (MTA) was placed (Figure 3C). A
The more severe injuries were treated sooner to prevent temporary restoration was placed, and the patient was
more unfavorable outcomes. Maxillary right lateral asked not to leave the clinic until the MTA (Angelus,
incisor had been avulsed and missed. The consequences Londrina, PR, Brazil) setting was completed, which
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Table 1. Radiograph and vitality test results by type of tooth
Tooth (universal Vitality tests Diagnosis
number)
Electric Cold Heat Palpation Mobility Percussion test
pulp test test test test test
Permanent maxil- - - - - - - Avulsed and missed
lary right lateral
incisor (7)
Permanent maxil- - - - - - Tender Necrosis, crown
lary right central fracture, intrusion
incisor (8)
Permanent maxil- - - - - Grade two - Necrosis and crown
lary left central fracture
incisor (9)
Permanent maxil- + + + - - - Subluxated and
lary left lateral vital
incisor (10)
Figure 1. A) Photograph taken in the first appointment; B)
Orthopantomograph taken in the first session
Figure 3. A) Initial condition of the intruded maxillary right
central incisor; B) Wire-composite splinting after surgical
extrusion; C) MTA plug placement; D) The periapical
Figure 2. Surgical extrusion of the intruded maxillary right radiography after obturation and composite resin restoration.
central incisor
took 4 hours. According to the treatment plan, further fracture resulting in pulp necrosis was made. The tooth
canal space was filled by a warm vertical technique underwent local anesthesia and isolation. The coronal
using the Obtura II system (Obtura Spartan, Fenton, segment was filed with a working length of 12 mm.
MO) and AH26 sealer (Dentsply, Tulsa Dental, Then, it was irrigated with a 0.5% sodium hypochlorite
Tulsa, OK, USA). Teeth were restored using the resin solution and filled with calcium hydroxide paste. The
composite Filtek Z250 (3M ESPE, St. Paul, MN, USA) tooth was temporarily restored using the resin-modified
(Figure 3D). glass ionomer (Figure 4A).
4th treatment session was 4 weeks later. Three-angled 5th treatment session was considered 4 weeks later.
radiographs were taken from the anterior region, and In this session, the left maxillary lateral incisor (no.
there was radiolucency around the permanent maxillary 10) was obturated by a warm vertical technique using
left lateral incisor (no. 10). The vitality tests showed the Obtura II system and AH26 sealer. The tooth was
necrosis because the patient did not react to any of the restored using the resin composite Filtek Z250 (Figure
tests but percussion. A diagnosis of horizontal root 4B).
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Figure 5. A) Follow-up photograph after 24 months. B)
Follow-up radiography of maxillary left lateral incisor after
24 months
Figure 4. A) Placement of calcium hydroxide paste in the
maxillary left lateral incisor. B) Maxillary left lateral incisor
after obturation and composite restoration
Figure 6. Timeline of the treatment plan and follow-up
With 2-, 4-, 8-, and 12-week intervals (Figure 5), no DISCUSSION
significant external root resorption was observed.
There were follow-up visits 2, 4, 8, 12, and 24 Simultaneous intrusive luxation and avulsion of
months after the first session (Figure 5), and no sign adjacent teeth is a rare phenomenon because the forces
of pathologic resorption, PDL widening, and apical causing these injuries have different mechanisms.
or peri-radicular radiolucency was observed in the However, combined injuries are common in severe
follow-up radiographs. Also, no unusual mobility was traumatic events. According to studies, teeth with
observed. The patient was at the end of the mixed crown fractures and luxation, regardless of the presence
dentition era, and the maxillary canines were about or absence of pulp exposure, are more likely to develop
to erupt. Thus, the parents were asked to consider a pulp necrosis and infection.8 Thus, any possible effort
temporary treatment for avulsed tooth, such as a fiber- should be made to preserve the pulp in the immature
reinforced composite bridge. However, they showed permanent tooth to ensure full root development. A
no interest. vast majority of TDIs occur in children and teenagers,
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who will face lifetime problems due to permanent have a higher survival rate compared to those with
tooth loss. However, an immature permanent tooth has fractures in the cervical third. This is due to the
a considerable ability for healing after traumatic pulp interposition of soft tissue between the fragments.5
exposure, luxation injury, or root fracture.9 If the follow-up sessions are neglected, there may be
potential consequences, including undetected necrosis
Optimistically, pulp and periapical tissues will heal and abscess, leading to tooth loss. Permanent maxillary
after the traumatic dentoalveolar injuries. However, left lateral incisor had an undetected root fracture that
various complications often develop, such as pulpal was diagnosed in the follow-up sessions using the
necrosis, apical periodontitis, tooth discoloration, clinical and radiographic examinations. As the fracture
external root resorption, and complete tooth loss in was located in the middle third of the root canal, there
some cases. The severity of damages highly depends was a possibility of maintaining the pulp vitality. The
on the trauma and related treatment.3 Intrusive luxation vitality tests were repeated in each follow-up session to
is the most severe traumatic dental injury and needs a perform an in-time endodontic intervention if needed
highly precise treatment. Moreover, this problem has in order to prevent further complications, including
a poorer prognosis compared to other dentoalveolar canal obliteration, necrosis of the coronal segment,
traumatic injuries. Teeth with intrusion may experience and inf lammatory resorption. However, the tooth
further complications, such as ankyloses, external showed no responses to vitality tests and was diagnosed
root resorption, and periodontal issues.5 Considering with necrosis. Thus, the coronal segment underwent
the depth of the intrusion, surgical extrusion may be endodontic treatment. No periapical radiolucency was
preferred to orthodontic extrusion and re-eruption. Due observed in the follow-up radiographic evaluations.
to high eruption potential, re-eruption is considered
in teeth with open or closed apices in 12-17-year-old Teeth with simultaneous crown fracture and luxation
patients.9 According to a systematic review by Al- are more likely to develop necrosis, which is the
Khalifa, 10 there is no significant difference in the main complication of periodontal ligament injury.
extrusion outcomes using the surgical and orthodontic Inf lammatory resorption is the third most severe
approaches. post-traumatic complication after intrusion and
root fractures.3, 11 Maxillary left central incisor had
Three factors contributed to damaged teeth play role a complicated crown fracture and did not respond
in success of treatment, which are root evolution to vitality tests in the first and second visits. Thus,
stage, patient’s age and severity of intrusion. 11 The endodontic treatment was performed to prevent
critical time for treating intrusive luxation injuries is unfavorable outcomes. Moreover, the MTA plug was
within 2-3 weeks. If the surgical approach is selected used for this tooth because the root was fully developed
for the intruded teeth, some factors, including the while the apex was open.
damage to the adjacent teeth and bone remodeling,
should be considered. Pulp extirpation time, splinting Maxillary right lateral incisor was avulsed and missed.
duration, and root canal filling are all important in According to the latest guidelines by the International
the success of the intrusive luxation treatment.12 The Association of Dental Traumatology, the management
present case had a high risk of necrosis due to poor of choice for this case was immediate replantation at
oral hygiene, complete tooth intrusion (more than 7 the site of injury or referral to a dentist with the avulsed
mm), and multiple lateral luxations. Therefore, surgical tooth kept in a medium storage. In tooth loss, patients
extrusion and semi-rigid splinting were performed, or their parents should be completely informed of the
which accelerated the fixation and allowed endodontic prognosis of the avulsed tooth as soon as possible,
treatment with calcium hydroxide paste that prevented and different treatment options should be discussed
further inf lammation of pulp and resorption. The with them. The treatment options may include a
patient was 9 years old, so the roots of the central resin-retained bridge, a removable partial denture,
incisors were fully developed but had open apices. or orthodontic space closure with or without resin
Therefore, the MTA plug was considered to seal the composite modification until a permanent prosthetic
apical foramen of both central incisors. According treatment could be available.15
to the guidelines, pulp sensibility was tested at each
appointment to evaluate the condition of each tooth and In such cases, follow-up using three-angled radiographs
perform an immediate endodontic treatment if needed and pulp vitality tests is essential for immediate
in order to prevent further unfavorable outcomes.7 diagnosis of complications, such as necrosis and
resor ption. In most cases, proper and in-time
Having a prevalence of 44.2%, pulp necrosis is the most endodontic intervention prevents tooth loss. In case
common complication of lateral luxation. However, of inflammatory resorption, especially external root
it is less common in immature teeth (17.5%). Several resorption, Cone Beam Computed Tomography
studies have emphasized the importance of follow-up (CBCT) is necessary to ensure the condition and
sessions in evaluating the vitality of damaged teeth.13, obtain further information for intervention.5 Dental
14
Teeth with fractures in the middle or apical third traumatic complications are unpredictable, and
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accurate diagnosis and treatment may be postponed 5. Soares Ditzel A, Tulio Manfron AP, Westphalen
to follow-up sessions. Post-treatment monitoring of FH, da Silva Neto UX, KowalczuzkA, Carneiro
the patient is the key factor in the prevention of further E, et al. Management of multiple dental trauma:
complications and costs. Regardless of the approaches Case report with eight-year follow-up. Iran Endod
recommended in the guidelines for traumatic event J. 2018;13(3):410-12.
management, it is necessary to consider the socio- 6. Nogueira Alancer M, Trujillo Lopez AB, da Silva
economic status and oral health of the patient for proper Neto UX, Kowalczuck A, Carneiro E, Ditzel
treatment selection. Also, it is important to inform the Westphalen VP. Management of Dental Intrusion
parents of the pediatric patients about the consequences and Lateral Luxation: Case Report with 10 Years
of traumatic dental injuries and the importance of Follow-up. Iran Endod J. 2019;14(1): 93-5.
follow-up sessions. In present case parents understood 7. Bourguignon C, Cohenca N, Lauridsen E, Flores
the importance of any effort to retain the injured teeth MT, O’Connell AC, Day PF, et al. International
and to completely cooperate in follow-up sessions but Association of Dental Traumatology guidelines
due to economic reasons they wanted to postpone any for the management of traumatic dental injuries:
treatment for the avulsed tooth. 1. Fractures and luxations. Dent Traumatol.
2020;36(4):314–30.
8. Levin L, Day PF, Hicks L, O’Connell A, Fouad AF,
CONCLUSION Bourguignon C, et al. International Association
of Dental Traumatology guidelines for the
The present case underwent surgical, endodontic, and management of traumatic dental injuries: General
restorative treatment to preserve the function, stability, introduction. Dent Traumatol. 2020;36(4):309–13.
and aesthetics of the injured teeth. Follow-up using 9. Braga R de A, Braga WDF, Girelli CFM, Lacerda
clinical and radiographic examinations is essential MFL, Coelho RG, Junqueira RB. Intrusive
to ensure the treatment’s efficacy and prevent further dislocation in permanent teeth: Review of literature
complications. A combination of effective treatment and clinical case report. Int J Odontostomatol.
and close follow-up can preserve the function and 2019;13(1):89-92.
aesthetics of the treated teeth, which can directly 10. AlKhalifa JD, AlAzemi AA. Intrusive luxation
impact the quality of life and emotional state of the of permanent teeth: a systematic review of factors
patient in adolescence. important for treatment decision-making. Dent
Traumatol. 2014;30(3):169-75.
11. Alencar MN, Lopez ABT, da Silva Neto UX,
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(Received May 4, 2021; Accepted November 11, 2021)
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