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Treatment of Luxation Traumatic Injuries

Definition and Classification in the Literature

Epidemiological investigations reveal a high incidence of dental injuries that may be related to predisposing factors, but they are primarily caused by accidents.1-6 The majority of dental injuries involve the anterior teeth and generally affect a single tooth, although certain types of trauma favor multiple injuries. Most reports indicate precise gender and age distribution as well as seasonal variations.

Injuries are divided into hard or periodontal tissue injuries. According to Andreasen,7 luxation injuries are defined by the following diagnostic criteria:

  • Subluxation -- Periodontal injury that causes loosening but not displacement of the tooth.
  • Intrusion -- Forced impaction of the tooth into the alveolar socket.
  • Extrusion -- Partial displacement of the tooth from its socket.
  • Lateral luxation -- Forced movement of the tooth laterally.
  • Exarticulation -- Total luxation of the tooth.

Subluxation and Exarticulation

Although luxation injuries may affect the periodontal structures and the blood supply of the pulp, the frequency of periodontal ligament (PDL) complications and pulp necrosis is rather rare in subluxation, as it does not imply displacement of a tooth in its alveolus. The only clinical indication of such events may be some loosening or sensitivity to percussion (Figure 1), and the incidence of pulp necrosis and root resorption processes are reported to be less than 5%.

One of the most dramatic (and least frequent) luxation injuries is the total luxation of a tooth following a traumatic injury (Figures 2-3-4-5). Exarticulation of teeth generally involves maxillary central incisors in primary and permanent dentition.8 Although reimplantation of avulsed permanent teeth is a widely accepted therapeutic measure, the long-term prognosis remains controversial, as many factors have been claimed to affect their success rate.9-11

The trauma of reimplantation can elicit extensive pulpal damage, which is healed by various pulpodentinal reactions. Microangiographic studies have demonstrated initial revascularization 4 days following reimplantation. This extends to half of the pulp cavity after 10 days and to the entire pulp cavity 30 days thereafter, primarily from the migration of new blood vessels.12,13 Since reparative dentin is already noticeable after 2 weeks in the apical third of the tooth, it has been hypothesized that odontoblasts can survive the reimplantation procedure.14 An open root apex and a narrow pulp cavity appear to create favorable conditions for the healing processes; the pulp of immature teeth recovers vitality, but revascularization rarely occurs if root formation is completed.15

Regeneration of nerve fibers is generally not observed prior to 1 month posttrauma and neither their number nor their diameter reaches normal levels.16 Pulpal healing is obviously essential for the endodontic prognosis of a reimplanted tooth, as well as for the periodontal healing. With assistance of the coagulum present following reimplantation or transplantation and reorganized by young connective tissue, reattachment at the cementoenamel junction is possible at 1 week and healing is completed after 2 weeks.

Root resorption and pulp diseases are the most frequent complications in reimplanted teeth.17-19 Teeth subjected to either extended extraoral storage or unsuitable storage media prior to reimplantation are more prone to develop severe root resorption. Experimental studies on cell cultures have shown that dry storage of 60 minutes can cause periodontal membrane (PDM) necrosis.20 Replanting teeth with necrotic PDM will result in extensive root resorption, whereas preventing PDM cells from drying during the extra-alveolar period promotes PDM healing similar to that of an immediately reimplanted tooth.20

According to previous findings, revascularization in mature teeth following reimplantation does not occur, whereas in immature teeth occurrence of revascularization is low, irrespective of the stage of root development, duration of extra-alveolar period, or storage conditions.21,22 As a high incidence of pulp necrosis is frequently reported in mature teeth -- even if pathways for pulpal infection after reimplantation have not been fully clarified -- awaiting pulp revascularization may predispose the tooth for failure.22 While the literature suggests that endodontic treatment could be postponed in reimplanted immature teeth,23 it should be instituted 2 to 3 weeks following reimplantation in teeth with complete root development to prevent contamination from nonvital pulp in the surrounding tissues.11

As bacterial contamination appears to be the critical factor of pulp revascularization and PDM healing processes, various methods of control (eg, topical or general treatment with antibiotics) and use of artificial storage media have been advocated. To date, no treatment has proven effective in controlling such procedures, which suggests that only limited conclusions can be drawn from experimental findings to increase the success rate of reimplantation.21

(Continued from page 1 )

Intrusion, Extrusion, and Lateral Luxation

While a general agreement exists concerning the treatment procedures (ie, repositioning and splinting) of luxation injuries, there is a large debate regarding the length of immobilization and the timing of interceptive treatments in follow-up periods. Acute treatment of luxation injuries varies from no treatment to repositioning and fixation for varying periods. Numerous investigations have been undertaken to disclose if splinting teeth may aid periodontal and pulpal healing. In an animal experiment, normal masticatory stimulation appeared to eliminate small resorption areas.24 In the same manner, it has been demonstrated that PDL recovered 70% of its original strength 14 days following extraction and reimplantation.25 As clinical healing of the periodontium occurs within 7 days by reattaching to the new junctional epithelium, cases with minor supporting tissue injuries (without alveolar bone support involvement) should not be splinted for more than 1 to 2 weeks. Splinting has also been used to increase the extent of pulp necrosis, due to less movement during fixation, which generally facilitates the ingrowth of new vessels.9

Since they were first used in maxillofacial fractures, the principles underlying tooth splinting have changed dramatically. The incorporation of arch bars and acrylic caps has influenced the demands of modern tooth fixation, and flexible arch wires or acid-etched splints are required. Less rigid, they allow limited vertical movement of the teeth and, therefore, reduce the risk of external root resorption.

These principles can be applied in cases of extrusive and lateral luxation, where a fixation by a flexible wire splint for 2 or 3 weeks is recommended, except when there is a concomitant alveolar bone support fracture. In those situations -- particularly in lateral luxation injuries -- an immobilization period of 4 to 6 weeks is necessary.

Extrusive luxations are treated by a careful repositioning and splinting of the displaced tooth for a period of 2 weeks (Figures 3-4-5-6-7-8). The healing process is generally uneventful, although the incidence of pulp necrosis (up to 26%) and root resorption phenomenon (possibly as high as 12%) requires regular radiological and clinical controls at least during the first year following the traumatic event.

Lateral luxations are often observed with other luxation injuries and -- when involving an extreme displacement -- are accompanied by alveolar bone plate fracture (Figures 9-10-11-12-13-14). In these instances, the repositioning process is generally forceful and requires a longer period of splinting (4 to 6 weeks minimum), as it must cope with the rhythm of bone healing modalities. The rate of pulp necrosis (up to 58%) and root resorption processes (up to 30%) is rather high, although it is (as for other luxation injuries) highly correlated with the stage of root development at the time of the trauma and with the intensity of the impact during the luxation procedure. In both extrusive and lateral luxations, the repositioning process must be carefully evaluated with proper radiological controls that require occlusal views in lateral luxations to assess the approximation between the alveolus and the root surface.

It must be stressed that -- in cases of late consultation -- the repositioning procedure may be too difficult to perform. The luxated tooth should then be allowed to realign spontaneously or should be orthodontically moved at a subsequent stage, following careful evaluation of pulpal and periodontal prognosis.

Intrusive luxations represent a significant challenge in dentoalveolar traumatology, as permanently intruded teeth exhibit high rates of pulp necrosis and root resorptions (as high as 85%). Immediate surgical repositioning of the intruded tooth may cause permanent loss of a significant alveolar bone support and must be strongly discouraged. It has been stated that intruded, partially immature teeth will re-erupt spontaneously within 2 to 3 months following the injury (Figures 15-16-17a-17b). Bearing in mind that high pulpal infection rates can result in inflammatory resorption processes and ultimately loss of the tooth in a 2- or 3-month period, it is now recommended to proceed to the rapid orthodontic extrusion of the tooth, which allows endodontic treatment if necessary. The clinical situation occasionally requires surgical uncovering of the tooth, if it has been completely intruded, and the entire orthodontic procedure can be performed in 4 to 6 weeks.

Clinical studies often show that complications from traumatic injuries (eg, pulp necrosis or root resorptions) generally develop during the year following the trauma. It may be advisable -- contrary to the procedures used for intruded permanent teeth -- not to institute any orthodontic treatment during that observation period. The relevant data in the scientific literature cannot confirm the increased potential of root resorption during orthodontic treatment of luxated teeth. Contradictory findings of different studies do not result in definitive conclusions.

Conversely, when evidence of inflammatory or replacement root resorption exists, orthodontic treatment should not be instituted. When inflammatory root resorption is evident, the endodontic status should be controlled prior to introduction of orthodontic therapy; in instances where replacement root resorption is evident, the ankylosed tooth cannot respond to the application of orthodontic force. The emergency treatment of dentoalveolar trauma is, therefore, critical, as it may influence the prognosis of any multidisciplinary treatment initiated following the observation period. The combined approach used in treatment of these traumatic injuries involves different specialized fields of dentistry and stresses the need for evaluation of the various treatment regimens. This will ultimately ease the decision-making process in the difficult therapeutic complications caused by traumatic loss or injury of anterior teeth.

 

*Senior Lecturer, Department of Orthodontics, University of Geneva, Geneva, Switzerland.

†Former Head, Department of Orthodontics, University of Geneva, Geneva, Switzerland.

‡Senior Lecturer, Department of Cariology, Endodontics, and Pediatric Dentistry, University of Geneva, Geneva, Switzerland.

 

References    

 

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