JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 148-152

Managing an extrusive luxation secondary to tongue thrust in an immature young permanent tooth. A case report and discussion


1 Department of Pediatric and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopedics, Bhojia Dental College and Hospital Baddi, Himachal Pradesh, India

Date of Submission01-Apr-2021
Date of Decision28-May-2021
Date of Acceptance03-Jul-2021
Date of Web Publication17-Jan-2022

Correspondence Address:
Dr. Aman Deep
Department of Pediatric and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_15_21

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   Abstract 


Traumatic dental injuries for the most part are unanticipated events that require prompt diagnosis and management. Often the scarcity of time and anxious environment created due to injuries confound its management and prognosis. Hence, a planned and organized approach to perform care, inevitably expedite procedures in a timely fashion. However, in different situations generally predispose nonestablishment of contemporary methods for management. Here, we present a case report, in which the management of extrusive injuries was affected by other surrounding factors that presumably decreased the prognosis of the tooth. A less novel method was instituted to manage the case of extrusive luxation affecting an upper anterior tooth in a young adolescent child. Since the extrusion of tooth was confounded by parafunctional habit and a palatal impacted supernumerary tooth, it remains a mystery that the secondary extrusion following traumatic extrusive luxation of the tooth could have been due to erupting forces generated by supernumerary tooth. Hence, preoperative evaluation and its management play a pivotal role in establishing the prognosis of traumatized tooth.

Keywords: Apexification, supernumerary tooth, tooth injuries


How to cite this article:
Deep A, Thakur S, Chauhan D, Chawla D. Managing an extrusive luxation secondary to tongue thrust in an immature young permanent tooth. A case report and discussion. J Int Clin Dent Res Organ 2021;13:148-52

How to cite this URL:
Deep A, Thakur S, Chauhan D, Chawla D. Managing an extrusive luxation secondary to tongue thrust in an immature young permanent tooth. A case report and discussion. J Int Clin Dent Res Organ [serial online] 2021 [cited 2022 May 28];13:148-52. Available from: https://www.jicdro.org/text.asp?2021/13/2/148/335868




   Introduction Top


Traumatic dental injuries (hereafter TDI) are one of the frequent injuries to manifest in humankind. These injuries can range from fracturing of teeth to crushing/fracturing of bone and soft-tissue contusions and lacerations. Prevalence of dental trauma varies widely between the different geographical areas, age groups, genders, and socioeconomic environments.[1] While in western countries like Canada, at 12–14 years of age TDI were less prevalent (11.4%) at the same age group in country like India, the prevalence was found to be 14.4%–33.8%.[2],[3] In a general consensus, gender distribution showed more prevalence of TDI among males as compared to females.[4] While when evaluating type of injuries, luxation injuries (subluxation– 38.6% and lateral luxation– 29.5%–57%) seemed to exceed the prevalence among other TDI in the primary dentition, on the other hand, enamel and dentin fractures predominate among permanent dentition.[5],[6]Extrusive luxation is a traumatic dental injury caused by the application of oblique forces over the dentition, resulting in loosening and partial displacement of the tooth out of its socket.[7] This invariably results in the disruption of periodontal apparatus and breaking of apical neurovascular bundle. Unfortunately, even if laterally luxated teeth are treated with repositioning and splinting, they can encounter long-term complications such as pulpal necrosis and periapical inflammation.[8] Henceforth, injuries need to be assessed carefully during preoperational period as the treatment provided immediately postinjury majorly influences the prognosis of the injured tooth.

Here, it is the representation of the management of a case with postoperational complication of an immature tooth suffering extrusive luxation.


   Case Report Top


A 9-year-old male reported to outpatient department with a chief complaint of extruded upper front tooth for 7 days. There was noncontributory past medical history and past dental history depicted traumatic injury sustained by the child 3 months back. back, when patient had fallen while playing and suffered extrusive luxation with respect to right maxillary central incisor. The patient was immediately rushed to private dental clinic where he received first aid and rigid splinting for 1 week. However, postsplint removal, since the patient manifested parafunctional habit of tongue thrusting. Over the period of 3 months, patient's mother gave the history of him using tongue to thrust the incisor, leading to again extrusive luxation of right maxillary central incisor. On intraoral examination, the patient had a mixed dentition with a total of 22 teeth present. Of these, tooth no. 74, 75, and 84 (FDI Notation) were grossly carious, whereas tooth no. 53, 16, 64, 65, 26, 36, 83, 85, and 46 were having smooth surface and pit and fissure carious lesions. The patient had Angle's Class I molar relation with generalized spacing present in anterior region. Extrusion of 3 mm from adjacent incisal edge was present with respect to 11 with slight labial positioning of the tooth. Grade III mobility on miller's scale was recorded for the tooth, whereas tooth no. 12, 22, and 33 were undergoing physiological tooth eruption.

The patient was advised for intraoral periapical radiograph to check for periodontal status of the teeth. However, the radiograph depicted a supernumerary tooth in palatal aspect of the extruded tooth along with all the anterior teeth with immature root apex. In addition, slight rarefaction could be seen around the affected tooth and hence due to this periradicular inflammation, extrusion of the tooth could have occurred supplemental to the habit. An occlusal radiograph was also prescribed to rule out any other anomaly and establish the position of supernumerary tooth [Figure 1].
Figure 1: (a) intraoral right lateral view. (b) Intraoral frontal view showing extruded 11. (c) Intraoral left lateral view. (d) Intraoral maxillary occlusal view. (e) intraoral mandibular occlusal view showing grossly carious dentition. (f) Anterior maxillary occlusal radiograph showing supernumerary tooth impacted behind extruded central incisor

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Treatment objectives

Since a lot of confounding factors influenced the prognosis of the extruded tooth, the initial treatment required checking the pulpal vitality of the extruded tooth. Followed by restoration of all the carious lesions affecting other tooth surfaces, extraction of the supernumerary tooth and other grossly carious teeth, repositioning of the extruded tooth, and finally interception of the tongue thrust habit.

Alternative treatment plan

Since the prognosis of the extruded tooth was rather poor, extraction of the extruded tooth along with supernumerary tooth followed by partial removable prosthesis could be done to later receive implant prosthesis, whereas habit interception and manifesting malocclusion could be corrected conventionally.

Treatment progress

Following thermal and electrical testing,[9] the status of the extruded tooth was found to be nonresponding, additionally since the tooth had immature root apex, endodontic therapy was started. Calcium hydroxide apexification was initiated following access opening and complete debridement of the canal, calcium hydroxide iodoform paste (Metapex) was placed within the canal and the tooth was restored with glass ionomer cement (GIC) [Figure 2]a. Glass ionomer restoration were done with respect to 16, 64, 65, 26, 36, and 46 and resin-modified GIC restoration was done on 75. Extraction of 74, 75 and 84 were done under local anesthesia. Following restorative phase, surgical phase needed to be started, in which envelope flap was raised to expose and extract the supernumerary tooth, and flap was sutured using 3-0 black silk suture [Figure 2]b, [Figure 2]c, [Figure 2]d. The patient was put on the maintenance phase for 4 weeks following which a removable tongue crib appliance therapy was instituted to intercept tongue thrusting habit [Figure 2]e and [Figure 2]f. Simultaneously root end status of the extruded tooth was checked in subsequent appointments. After 7 months of follow-up, the periapical radiograph showed root end closure and reduced mobility in the tooth. The tooth showed Grade I mobility when evaluated on Miller's scale. Following this, root canal of 11 was reentered, and root end closure was checked using large gutta-percha point. The tooth was obturated with gutta-percha and restoration with GIC was done. In addition, tongue thrust appliance was removed as the patient started to position tongue correctly and reduction in tongue thrust was seen. A Hawley's appliance was fabricated to retract the tooth back into the arch form with sequential activation of labial bow was done. Once the tooth had been aligned, the extruded tooth was reshaped to adjacent tooth crown length [Figure 3]. The patient was satisfied with the esthetics achieved and hence was put to follow-up every 6 months.
Figure 2: (a) intraoral periapical radiograph showing calcium hydroxide apexification started. (b) Reflection of palatal flap to expose supernumerary tooth. (c) 3-0 black silk suture in place. (d) Extracted supernumerary tooth. (e) Frontal view to tongue thrust appliance in place. (f) Intraoral removable tongue thrusting appliance

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Figure 3: (a and b) hawley's appliance for retraction of extruded tooth. (c) Mandibular occlusal view showing transitional dentition. (d) Tooth reshaping done of the extruded tooth. (e) Maxillary occlusal view post tooth reshaping. (f) Mandibular occlusal view (g) Intraoral periapical radiograph showing periodontally stable tooth

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   Discussion Top


There continues to be paucity of studies regarding traumatic dental extrusion injuries, and the proposed guidelines for the treatment are not based on strong evidence. Various studies depict that there is an insufficient evidence that one type of treatment is superior to another.[10],[11],[12] However, the most important points to be discussed here are the degree of root development, degree of tooth mobility, the maintenance of pulpal vitality, and the treatment time.[7] In general, the treatment of extrusive luxation revolves around three treatment options: manual reposition immediately post luxation injury, surgical repositioning, and orthodontic intrusion.[13],[14] The first option of manual reposition was not feasible in this case as the time elapsed posttraumatic extrusion had led to healing and the formation of bone in the periapical region, while surgical repositioning/intentional replantation invariably results in more damage to the periodontal ligaments and neurovascular bundle in an immature permanent tooth.[7] Inadvertently, it also poses the great risk of replacement resorption. Finally, orthodontic intrusion remains to be the best treatment line in case with immature root apex as a study by Ebrahim and Kulkarni[12] showed that institution of orthodontic intrusion in teeth with early development and open apices led to profound increase in capacity of revascularization after trauma. Moreover, gradual repositioning preserves the vitality of the tooth, prevents ankylosis, and encourages periodontal healing. The majority of studies testify to this fact and choose this as their first option of choice in such case.[11],[15] However, despite all these advantages, a major drawback of this treatment option is the time and appointments required to establish this treatment plan. Moreover, cost and economics also play a confounding factor to this treatment option. Development of long junctional epithelium following intrusion in such case also predisposes the tooth to compromised periodontal health and hence affecting its long-term prognosis. In our case, since the patient belonged to a far-flung village area and had infrequent appointments, so this treatment option could not be instituted.

Henceforth, tooth reshaping had to be done once the tooth was aligned, and root end closure was achieved. Although a major drawback of this treatment line results in reduced crown root ratio; however, since the tooth was stable, and the patient was satisfied with the esthetics, this treatment plan was followed.

Such type of treatment falls under semiconservative treatment option containing enameloplasty or coronoplasty. Al Ahmari et al.[16] describes this type of treatment for supraerupted teeth and is mainly dependent on the amount of supraeruption. If supraeruption is between 0.1 and 2 mm, it can be managed by enameloplasty or coronoplasty. If the amount of supraeruption exceeds 1.5 mm, it can be corrected by intentional root canal treatment followed by fixed prosthetic crown.

Another novel treatment option described by Batra et al.[17] includes the successful use of removable Hawley's appliance with modified labial bow and combination of elastics to intruded the tooth. It proved to be an effective treatment alternative in patients with extruded anterior tooth and could have been effective in children with transitional dentition; however, patient compliance is still a pivotal factor to its successful use.


   Conclusion Top


The paucity of treatment guidelines continues to shade the topic of extrusive tooth luxation in an immature tooth. Tooth reshaping appeared to be a viable treatment option in this particular case. However, such treatment line cannot be advocated as long-term follow-up of this case is still awaited.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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2.
Kumar A, Bansal V, Veeresha KL, Sogi GM. Prevalence of traumatic dental injuries among 12- to 15-year-old schoolchildren in Ambala district, Haryana, India. Oral Health Prev Dent 2011;9:301-5.  Back to cited text no. 2
    
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Fakhruddin KS, Lawrence HP, Kenny DJ, Locker D. Etiology and environment of dental injuries in 12- to 14-year-old Ontario schoolchildren. Dent Traumatol 2008;24:305-8.  Back to cited text no. 3
    
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Altun C, Ozen B, Esenlik E, Guven G, Gürbüz T, Acikel C, et al. Traumatic injuries to permanent teeth in Turkish children, Ankara. Dent Traumatol 2009;25:309-13.  Back to cited text no. 4
    
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Díaz JA, Bustos L, Brandt AC, Fernández BE. Dental injuries among children and adolescents aged 1-15 years attending to public hospital in Temuco, Chile. Dent Traumatol 2010;26:254-61.  Back to cited text no. 5
    
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Eyuboglu O, Yilmaz Y, Zehir C, Sahin H. A 6-year investigation into types of dental trauma treated in a paediatric dentistry clinic in Eastern Anatolia region, Turkey. Dent Traumatol 2009;25:110-4.  Back to cited text no. 6
    
7.
Amaral MF, de Almeida MM, de Faria LP, Brandini DA, Poi WR, Okamoto R. Treatment of extrusive luxation in permanent teeth: Literature review with systematic criteria. J Contemp Dent Pract 2017;18:241-5.  Back to cited text no. 7
    
8.
Andreasen FM, Andreasen JO. Extrusive luxation and lateral luxation. In: Andreasen JO, Andreasen FM, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford: Blackwell; 2007. p. 411-27.  Back to cited text no. 8
    
9.
Alghaithy RA, Qualtrough AJ. Pulp sensibility and vitality tests for diagnosing pulpal health in permanent teeth: A critical review. Int Endod J 2016;50:135-42.  Back to cited text no. 9
    
10.
Martins WD, Westphalen VP, Perin CP, Da Silva Neto UX, Westphalen FH. Treatment of extrusive luxation by intentional replantation. Int J Paediatr Dent 2007;17:134-8.  Back to cited text no. 10
    
11.
Elbay ÜŞ, Baysal A, Elbay M, Sarıdağ S. Multidisciplinary approach to delayed treatment of traumatic teeth injuries involving extrusive luxation, avulsion and crown fracture. Oper Dent 2014;39:566-71.  Back to cited text no. 11
    
12.
Ebrahim FH, Kulkarni G. Fixed orthodontic appliances in the management of severe dental trauma in mixed dentition: A case report. J Can Dent Assoc 2013;79:d131.  Back to cited text no. 12
    
13.
Demir B, Demiralp B, Güncü GN, Uyanik MO, Cağlayan F. Intentional replantation of a hopeless tooth with the combination of platelet rich plasma, bioactive glass graft material and non-resorbable membrane: A case report. Dent Traumatol 2007;23:190-4.  Back to cited text no. 13
    
14.
Lauridsen E, Hermann NV, Gerds TA, Ahrensburg SS, Kreiborg S, Andreasen JO. Combination injuries 3. The risk of pulp necrosis in permanent teeth with extrusion or lateral luxation and concomitant crown fractures without pulp exposure. Dent Traumatol 2012;28:379-85.  Back to cited text no. 14
    
15.
Sübay RK, Kayataş M, Caniklioğlu C. Delayed multidisciplinary management of an extrusively luxated maxillary central incisor. Dent Traumatol 2007;23:82-4.  Back to cited text no. 15
    
16.
Al Ahmari NM, Aldhalail MA, Abidi NH, Mohamed MS, Alraawi MA, Al Moaleem MM. Techniques for management of supraerupted teeth prior to prosthetic treatment: Updated review. Biosci Biotech Res Commun 2020;13:261-73.  Back to cited text no. 16
    
17.
Batra P, Miglani R, Saalim M. A novel approach to intrude incisor by removable orthodontic appliance. J Clin Stud Med Case Rep 2015;2:14.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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