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Brazilian Journal of Dental Traumatology (2010) 2(1): 17-21© 2010 Sociedade Brasileira de Traumatologia DentariaISSN 2175-6155http://www.sbtd.org.br/journal

A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA

Rosana Belchior Miranda1, Marılia Fagury Videira Marceliano-Alves2, Marcelo Rolla de Souza3,Sandra Rivera Fidel4 and Rivail Antonio Sergio Fidel5

Received on June 10, 2010 / Accepted on August 11, 2010

ABSTRACT

Unfortunately, dental trauma is a common event among teenagers practicing sports. The injuries may range from involving only the teeth to beingassociated with a complex oral traumatism. The prognosis depends on a good diagnosis and an appropriate treatment plan. This study presentsa clinical case of a 15-year-old male, who had an accident during a soccer match. The trauma affected three teeth, their periodontal supportsand oral tissues. A severe intrusion committed the #21 tooth and both #11 and #12 teeth suffered subluxation. The teeth suffered crown fracture,without pulp exposure. Upon urgency visit the professional carried out the splint with orthodontic wire to fix the #11 and #12 teeth, besides thesuture of gingival tissue laceration. The patient was designated to Orthodontics for extrusion of the #21 tooth, which was essential to endodonticand restorative treatment. Pulp sensitivity of #11 and #12 teeth was tested for 7 months after trauma resulting in negative response. This conditionled to endodontic indication to both of them. Sixteen months after the trauma, periapical radiograph showed a radiolucent image limited aroundthe root apex of the #21 tooth that was, then, submitted to periradicular surgery. At 4 years follow-up, the area seemed healthy and the periapicalradiograph revealed evidence of bone repair.

Keywords: Dental trauma, intrusion, oral surgery.

Correspondence to: Rosana Belchior Miranda

R. Sorocaba, 115/901, Bl. 2, Botafogo, 22271-110 Rio de Janeiro, RJ, Brasil – E-mail: rosanabelchior@uol.com.br1DDS, MSc, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil.2DDS, MS, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil.3DDS, MS, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil.4DDs, MSc, PhD, Department of Integrated Clinical Procedures (Proclin), State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.5DDs, MSc, PhD, Endodontics Department, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

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18 A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA

INTRODUCTION

Oro-facial injuries are commonly result from assaults, accidents withvarious means of transport, falls or during sports-related activities[2, 9, 23]. They constitute frequent urgency situations at dental offi-ces.

Dental traumatic injury may include from enamel fracture to totaltooth loss. Predominantly, this type of trauma is seen especially ingrowing male school-age individuals [4, 6, 19, 21]. The injuries thatinvolve front teeth may result in unfavorable functional and aestheti-cal effects, cause painful sintomatology and directly affect self-esteem[4, 6, 14].

Enamel and dentin fractures without pulpar exposure have favora-ble prognosis, even in cases of late treatment; however, dental care isrequired for evaluation, treatment and proservation of the case. Coro-nary fracture with pulp exposure, concussion, subluxation and intrusiveluxation are regarded as mild-severity injuries, but they require imme-diate care [2, 5, 6, 9]. Avulsion, root fracture and alveolar fracture areregarded as more serious conditions, and must also receive promptcare [3, 9, 16].

Intrusive luxation means the axial displacement of the tooth insidethe socket [1, 3, 7]. Traumatic intrusion represents 0.3 to 2% of thetraumas affecting the permanent teeth [9, 11]. Due to the nature of thisinjury, with damage to gum tissue, periodontal ligament, alveolar bonewall and pulp, this is the scenario for a series of complications, inclu-ding loss of gingival attachment, marginal bone loss, root resorption,ankylosis, pulp necrosis and paralysis of root formation in immatureteeth [6].

At the moment of the impact, the periodontal ligament is compres-sed against the alveolar bone wall, fiber cutting occurs, as well as bonewall fracture and section of the neurovascular bundle, which results inpulp necrosis. In addition to the mechanical trauma, an intruded toothmay be contaminated by oral bacteria, with consequent risk of infec-tion. Andreasen & Andreasen [6, 8] consider that the cure for traumaby intrusion is complex, resulting in complications in the cicatrizationprocess. The authors also report that intruded teeth with incompleteroot development usually re-erupt spontaneously, which could also oc-cur to those with complete root formation, but it could take months,thus allowing a root resorption process. Therefore, orthodontic extru-sion was indicated, enabling the endodontic treatment after coronaryexposure [13].

This work aimed at reporting a clinical case of dental trauma withmultidisciplinary treatment, performed at the Santos-Dumont DentalClinic of Brazilian Air Force.

CASE REPORT

A 15-year-old Caucasian male came to the Santos-Dumont Dental Cli-nic of Brazilian Air Force (Rio de Janeiro, RJ, Brazil) in an urgency

condition because of a collision during a soccer match. The situa-tion involved his maxillaries left (#21) and right (#11) central incisorsand the maxillary right lateral incisor (#12). After carefully cleaningand sewing of gingival laceration at that area (black braided silk 4.0 –Ethiconr – Johnson & Johnson, Sao Paulo, Brazil), it was possible toevaluate the extension of the traumatism.

The clinical examination showed that all the involved teeth hadtheir crowns fractured without pulp exposure. Moreover, the #11 and#12 teeth showed mobility and did not demonstrate sensitivity to acold test with refrigerant gas (Endo-Frostr – Roeko/Langenau – Ger-many) such as the #21 tooth.

The periodontal injury consisted of subluxation of #11 and #12teeth and a severe intrusion of the #21 tooth, revealed by radiographicexamination (Figure 1).

� Figure 1 – Panoramic radiographic examination.

Orthodontic wire has been used as a semi-rigid contention to set-tle the teeth (Figure 2). Two days later the splint was removed fromthe #21 tooth to allow some axial spontaneous movement.

a) b)

� Figure 2 – a) semi-rigid contention; b) periapical radiograph.

The suture was removed three days later of the first visit and thelight-curing resin restorations were immediately performed to makeaesthetics better and to protect the dentin-pulp complex.

Semi-rigid contention was established for three weeks. At thatmoment, the patient began an orthodontic treatment to get the #21tooth extrusion in order to bring it back to its original position (Fi-gure 3). Six months later, the orthodontic appliance was removed andthe #21 tooth endodontic treatment was carried out.

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a) b)

� Figure 3 – a) #21 tooth orthodontic extrusion; b) periapical radiograph.

After a month, patient has come back to review the #11 and #12teeth pulp condition that once again revealed negative response to sen-sitivity cold test, besides the periapical radiograph showed external rootapical resorption of #21 tooth (Figure 4). Thus the #11 and #12 teethwere undergone to endodontic treatment and the #21 tooth to endodon-tic retreatment.

� Figure 4 – #21 tooth endodontic treatment at a month follow-up.

Six months after the endodontic retreatment, the clinical examina-tion showed that there was an increase of volume, without symptom,at #21 tooth apical area corresponding to a well defined radiolucentimage revealed by the periapical radiograph (Figure 5).

� Figure 5 – Periapical radiograph 6 months after the #21 tooth endodontic retreat-ment showing a radiolucent image around its root apex.

The perirradicular surgery was planned for this area and consistedof apical lesion curettage, apicectomy and retrograde filling with mine-ral trioxide aggregate (ProRoot 2 MTAr – Dentsply, USA) (Figure 6).

a) b)

� Figure 6 – a) periapical lesion removed by curettage; b) surgical bone site showingthe #21 tooth apicectomy.

Six months after surgery, the patient was in excellent conditionwith neither symptom nor signal of any problem. Periapical radiographsuggested bone formation (Figure 7). Despite of the extensive surgi-cal area, it was interesting to notice that there was not #22 tooth in-volvement such as revealed by a positive response to sensitivity pulptest. The histopathological test confirmed the diagnosis hypothesis ofa periapical cystic lesion.

a) b)

� Figure 7 – 6 months follow-up: a) clinical aspect; b) periapical radiograph.

Patient returned after four years when the clinical and radiographicexaminations found the teeth involved in this case of dental trauma andtheir periodontal tissues healthy (Figure 8).

� Figure 8 – Periapical radiograph at 4 years follow-up.

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20 A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA

DISCUSSION

The consequences of dental trauma in permanent teeth may be asfollows: change of color, mobility, pulp necrosis, bone and dentalresorptions – which can occur by lack of immediate treatment or in-dividual prognosis of the case [1, 3, 22, 12].

According to Andreasen, Bakland, Matras and Andreasen [9], thefrequency of injuries by intrusive luxation is low (1.9%), but the treat-ment is complex. Dentinal protection was recommended in case ofintrusion-related crown fracture, which was first performed in the casereported, as the exposed dentin may allow bacterial invasion. Besides,the aesthetical recovery allowed that the patient returned to his nor-mal activities.

The most common complication of intrusive luxation is pulp ne-crosis, due to ischemic changes, probably because of compression ofthe neurovascular bundle [1, 3, 10, 20]. As soon as the dental repos-itioning was achieved, the endodontic treatment was executed; how-ever, there was still apical resorption and further development of theperiradicular lesion.

According to Andreasen & Andreasen [8], the chosen treatmentfor the repositioning must be the orthodontic extrusion, so that thecrown is exposed as soon as possible, thus enabling the endodontictreatment, which is a means of preventing external root resorption thatoccurs, according to the same authors, around 3 weeks after. In thiscase, the crown was exposed only within six months of traction. Con-sidering the severity of the intrusive luxation, there must have beendamage to the periodontal membrane and the root surface, accordingto studies by several authors [1, 3, 10, 17].

The authors suggest a 5-year follow up period, due to the risk offurther complications during the cicatrization process, such as resorp-tion of the root surface [1, 3, 10, 17, 20].

Fidel et al. [15] affirmed that intrusion treatment is a challenge,and that the focus must be on the most serious damage and the cureprognosis. Therefore, in the case presented, the surgery was plannedin order to perform curettage of the periradicular lesion, carry out anapicectomy and, also, refill with a bone-formation biocompatible andbiostimulating material – MTA [3, 25, 26]. In recent literature review,Torabinejad and Parirokh [27] reaffirmed that MTA was firstly recom-mended as root-end filling material and, by analyzing a great deal ofstudies, they emphasized the superior results for this material regard-ing the chemical and physical properties as well as the antibacterialactivity, the excellent sealing ability and biocompatibility.

The literature shows that long-term follow up of traumatized pa-tients is fundamental [7, 8, 18]. Such fact was evident in the case pres-ented, as #21 tooth was certainly preserved due to regular follow upof the patient for 18 months, which allowed the interventions to occur

at those very moments when the changes were observed. Although thepatient has not responded further calls and had returned after four years,one can observe the satisfactory result of the case.

Souza-Filho et al. [24] reaffirmed that dental traumatic injuries inthe emergency service is high, and that it is extremely important todivulge the preventive and educative approach on dental traumas,especially in educational institutions, raising the professionals’ awa-reness on the issue, since urgency attitudes at the accident site mayimprove the quality of life [2].

CONCLUSION

The occurrence of dental trauma is frequent in children and teenagers.The first aid to the patient, diagnosis and correct conduct in relation tothe trauma, as well as the long-term proservation are extremely impor-tant for the prognosis and maintenance of the tooth in the oral cavity.The long follow up of the patient and the interventions carried out atproper moments determined the success of the case presented.

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