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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 178-181

Management of dental trauma-how to manage lateral luxation injury


1 MDS Pedodontics, UCMS (University of Delhi) & GTB Hospital, Delhi, India
2 Senior Resident, Dept. of Dental and Oral surgery, Lady Harding Medical College, Delhi, India
3 Assistant professor Dept. of Dentistry, IGIMS, Patna, India

Date of Submission08-Jun-2019
Date of Acceptance16-Jul-2019
Date of Web Publication20-Nov-2020

Correspondence Address:
Krishna Prasad Biswas
Senior Resident, Dept. of Dental and Oral surgery, Lady Harding Medical College, Delhi
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Traumatic dental injuries are a trivial dental issue affecting teeth and their supporting structures. This case report describes a clinical case of dental trauma in an 18 year old girl which resulted in laceration of upper lip along with affecting the dentition in the form of lateral luxation, subluxation, uncomplicated and complicated crown fracture in her anterior maxillary and mandibular dentition. The management included suturing of laceration followed by repositioning of teeth by digital pressure and stabilization of teeth with the help of a semi rigid splint, root canal treatment for tooth 11, 21 and 31 followed by removal of splint when the teeth were reportedly asymptomatic and composite build up to re-establish the aesthetics for the patient. The follow up was done up to 1 year and no periapical pathology or complications were observed and the patient was relatively asymptomatic thus indicating successful intervention.

Keywords: Dental trauma, Lateral luxation, Ellis fracture


How to cite this article:
Kaushal D, Biswas KP, Mishra N. Management of dental trauma-how to manage lateral luxation injury. J Indira Gandhi Inst Med Sci 2019;5:178-81

How to cite this URL:
Kaushal D, Biswas KP, Mishra N. Management of dental trauma-how to manage lateral luxation injury. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2021 Oct 26];5:178-81. Available from: http://www.jigims.co.in/text.asp?2019/5/2/178/301108




  Introduction: Top


Lateral luxation is used to describe tooth displacement in any direction other than axial. Subluxation injury of tooth may occur with abnormal loosening of tooth supporting structures but without displacement.[1]

Epidemiological surveys indicate a high prevalence of traumatic dental injuries especially during home accidents or sports activities. The frequency of lateral luxation injury has been reported to be around 11% in traumatized permanent dentition and 6% for subluxation of teeth.[2] Luxation injury of tooth is usually considered to be due to compression and severing of periodontal ligament, often accompanied by fracture of labial bone plate, disintegration of marginal bone, and severed neurovascular supply reaching pulp.[1],[3],[4] It may usually involve the maxillary anterior region in both primary and permanent dentition.[5]

Diagnosis is made on the basis of clinical and radiographic observations.6Radiographs of the injured region taken at different horizontal and vertical angulations aid in diagnosis.[7] Lateral luxation may appear as dislocation on radiographic examination with increased periodontal space apically with apex displace labially which appears mostly on occlusal or eccentric exposures.[8]

Clinically, the crown of a laterally luxated tooth may be displaced and forced either labially or lingually, more commonly lingually thus displacing the apical portion of tooth labially and fracturing the alveolar bone and root may get locked in this position[9] thus may or may not show abnormal mobility, may show a metallic sound on percussion no tenderness to percussion and no positive response to sensibility testing.[10]

Lateral luxation injury may be managed by reduction of fracture, splinting, clinical and radiographic observation of outcome, endodontic treatment and extraction as per requirement.[11]

The present case report describes the attempt to rehabilitate the traumatized dentition to an acceptable level so that the patient can again lead a normal day to day life without any concerns.


  Case Report: Top


An 18 year old girl reported to the department of oral and maxillofacial surgery, AIIMS Patna, with a chief complaint of dental trauma due to history of fall from stairs and subsequently being hit by the edge of the stairs thus leading to laceration of upper lip, lateral luxation of 21, subluxation and Ellis class I fracture of tooth 11, Ellis class II fracture of 22 and Ellis class III fracture of 31 [Figure 1]. The occlusion was evaluated and was found to be normal posteriorly with no hindrance or difficulty in opening and closing of mouth.
Figure 1: Pre-treatment photograph of the patient showing sutures placed on upper lip and lateral luxation of 21 with subluxation and enamel fracture of 11 and complicated crown fracture w.r.t tooth 21 and 31.

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Temporomandibular joint was evaluated for any involvement both clinically and radiographically and it appeared unaffected.

Radiographic examination was done and IOPA revealed a fracture line extending through enamel dentin and encroaching pulp with widened periodontal ligament space with respect to tooth 21 and a fracture line extending from enamel and dentin nearing pulp with respect to 22. Tooth 11 reportedly had no appreciable radiographic findings except for small chip fracture of enamel not appreciable on radiograph [Figure 2]a. The tooth 31 showed fractured enamel,dentin and extension of fracture till the pulp chamber outline [Figure 2]b. Pulpal sensibility test was done using cold test (roeko endofrost) and no response was observed.


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The patient was counselled and stress reduction was done followed by suturing of laceration on upper lip after administration of local anaesthesia (2% lidocaine with 1:100000 epinephrine). Digital palpation and repositioning of teeth was done from its locked position after anaesthetic infiltration and stabilized using flexible wire and composite splint with two normal adjacent teeth also included in splint [Figure 3]. Proper access was gained for pulp extirpation in already exposed pulp chamber of tooth 31, followed by removal of small amount of involved pulp with round bur followed with copious irrigation with normal saline. Partial pulpotomy was attempted to preserve the vitality of pulp. Calcium hydroxide was placed in 31 as a pulp medicament for two weeks and sealed with temporary restoration.[Figure 4] A calcium hydroxide subbase and temporary GIC restoration was done w.r.t 21 and 22 so as to seal the exposed dentinal tubules due to uncomplicated crown fracture. Antibiotic prophylaxis and analgesic were advised (amoxicillin 500mg 8 hourly for 5 days and ibuprofen 400mg twice daily for 5 days). Chlorhexidine mouth rinse was advised to the patient to be swished in mouth every morning and at night for maintaining adequate oral hygiene post trauma for 2 weeks. The patient was also advised to take soft diet for the next two weeks till she returns for follow up visit. In the second visit the pulpal sensibility still remained to show no response and the integrity of splint was checked and was found to be intact with no abnormal loosening. A bevel was created around teeth 21 and 22 with the help of a tapered fissure bur for retention of restoration and then composite restoration was completed using sandwich technique with GIC and composite w.r.t tooth 11,21 and 22.
Figure 3: Repositioning of teeth along with splinting with wire and composite splint

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Figure 4: Partial pulpotomy performed w.r.t tooth 31.

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Pulpal condition was followed up for tooth 11, 21 and 31 after 4 weeks, but the patient returned with severe pain in 21 and 31 teeth indicating irreversible pulpal damage, hence root canal treatment was planned for them and pulp extirpation followed by placement of intracanal medicament calcium hydroxide was done for both the teeth. Teeth were splinted for a duration of 4 weeks therefore the splint was carefully removed without reducing excessive tooth structure and no abnormal mobility was observed post removal of the splint. After 2 weeks follow up, 21 and 31 were reportedly asymptomatic with no signs of pain or discomfort but the patient had severe pain in tooth 11, pulp extirpation followed by calcium hydroxide placement was done as a treatment measure and a recall was scheduled after 2 weeks. In the next visit, all 3 teeth 11,21 and 31 were asymptomatic hence were obturated with gutta percha using cold lateral condensation technique and sealed with GIC( Dentsply Type IX GIC) [Figure 5]. Composite restoration was done with respect to 31 and finishing of all composite restorations was done with composite finishing burs [Figure 6]. Subsequently, follow up was done around the 8th week, 6 months and 1year post trauma[Figure 7], and the teeth were asymptomatic with clinical and radiographic signs of healing periodontium, but with healing periapical pathology no signs of resorption of tooth or marginal bone were noticed.
Figure 5: post obturation radiograph w.r.t teeth 11,21,31.

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Figure 6: Final post-treatment photograph with completed composite build up w.r.t 11,21,22,31

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Figure 7: 1 year follow up post completion of treatment.

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  Discussion: Top


Lateral luxation of teeth occurs due to displacement of teeth in any other direction other than axial. Subluxation injury of tooth may occur with abnormal loosening of tooth supporting structures but without displacement.[1] The force an direction of impact may decide and predispose to a variety of luxation injuries accounting for almost 15-61% of all dental injuries.[5] Most frequently two or more teeth may be luxated simultaneously and primarily involve the maxillary central incisor region.[5],[12] In the present case the patient had a fall thus leading to trauma to the upper anterior maxillary teeth and upper lip.

Clinical and radiographic examination with periapical radiographs at different angulations and an occlusal radiograph may aid in diagnosis of the type of trauma, the extent of injury and the necessary intervention required. Additionally CBCT may further help in diagnosis.[13],[14]

Displaced and luxated teeth may undergo pulpal and periodontal damage.[15] Immediate repositioning of the tooth is preferred as it allows avoiding demanding procedure in the future thus restores occlusal function and esthetics.[16],[17] The displaced teeth are stabilized through adjacent sound teeth[18] using flexible splints for a short period as they are more effective.[19] The international association of dental traumatology advises to splint the tooth for 4 weeks and for an additional 3-4 weeks in case of marginal bone breakdown.[20] So splinting for a duration of 4 weeks was preferred in the present case. Many splints have been suggested, but regardless of the type used, flexibility and passivity of wire is essential to promote bone regrowth and periodontal fibre rearrangement.[21].Orthodontic wire and composite splint was used to stabilize the teeth in the present case as they reduce the chances of complications like pulp canal obliteration, ankylosis and root resorption[22] apart from being cheaper In cost and easy availability.[23]

Since all teeth showed severe pain in follow up appointment due to pulp necrosis, root canal treatment was done for teeth 11,21 and 31. In teeth 11 enamel fracture with concomitant subluxation was observed and it has been reported that enamel fractures with concomitant luxation injury might result in pulp necrosis in 8.5% of the cases.[24] Tooth 21 was laterally luxated and locked in its bone. Andreasen and Vestergaard-Pedersen reported that laterally luxated teeth with mature apices were most likely to develop necrosis than immature apex.[8] Other most likely consequences of trauma that have been reported include pulp canal obliteration, inflammatory or replacement resorption and ankylosis. The presence of necrosed periodontal ligament fibres across root surface may enhance resorption of cementum and dentin by osteoclasts from adjacent bone marrow followed by replacement with bone by osteoblasts.[10] Ankylosis of permanent incisor in a child and adolescent patient might lead to an inevitable loss of tooth and localised arrest of alveolar bone growth.[25]

After root canal treatment had been completed, the lost tooth structure w.r.t to tooth11, 21,22 and 31 was replaced with composite build up and restoration to restore the aesthetics as the patient being a female and her guardians had a primary concern about tooth structure loss compromising the patients dentofacial aesthetics.

Follow up for the case was done at 2 weeks, 4 weeks, 6-8 weeks, 6 months and an year and the patient was reportedly asymptomatic.[20] At 1 year follow up the patient was reportedly asymptomatic with a healing periapical area and deposition of bone with no sign of mobility, pain on percussion.


  Conclusion: Top


Based on this case report it can be concluded that though lateral luxation injury may lead to initial loss of aesthetics and function but immediate treatment intervention results in better prognosis with fewer complications.



 
  References Top

1.
Andreasen JO, Bakland LK, Flores MT, Andreasen FM, Andersson L (2003) Classification of dental injuries. In: Andreasen JO, Bakland LK, Flores MT, Andreasen FM, Andersson L (Eds.), Traumatic dental injuries - a manual. (2nd edn), Wiley-Blackwell, Oxford, UK, p. 16-17 .  Back to cited text no. 1
    
2.
Borum MK, Andreasen JO. Therapeutic and economic implications of traumatic dental injuries in Denmark ;an estimate based on 7549 patients treated at a majr trauma centre. Int J Paediat Dent 2001;11:249-58.  Back to cited text no. 2
    
3.
Andreasen JO, Bakland LK, Matras RC, Andreasen FM (2006) Traumatic Intrusion Of Permanent Teeth. Part 1. An Epidemiological Study Of 216 Intruded Permanent Teeth. Dent Traumatol 22(2): 83-89.  Back to cited text no. 3
    
4.
Neto, JJ, Gondim JO, de Carvalho FM, Giro EM (2009) Longitudinal Clinical And Radiographic Evaluation Of Severely Intruded Permanent Incisors In A Pediatric Population. Dent Traumatol 25(5): 510-514.  Back to cited text no. 4
    
5.
Andreason JO. Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1298 cases. Scan J Dent Res 1970;78:329-42.  Back to cited text no. 5
    
6.
Andreasen FM, Andreasen JO.Diagnosis of luxation injuries:the importance of standardized clinical, radiographic and photographic techniques in clinical investigations. Endod Dent Traumatol 1985;1:160-9.  Back to cited text no. 6
    
7.
Andreasen FM, Sewerin I, Mandel U, Andreasen JO. Radiographic Assessment of Simulated resorption cavities. Endod Dent Traumatol “1987;3:21-7.  Back to cited text no. 7
    
8.
ANDREASEN FM, VESTERGAARD PEDERSEN B. Prognosis of luxated permanent teeth- the development of pulp necrosis. Endod Dent Traumatol “1985;1:207-20.  Back to cited text no. 8
    
9.
Andreasen FM, Andreasen JO. Treatment of traumatic dental injuries. Shift in strategy. Int J Technol Assess Health Care. 1990;6:588-602.  Back to cited text no. 9
    
10.
Andreasen JO, Andreasen FM, ed. Classification, etiology and epidemiology. IN: Textbook and color atlas of traumatic injuries to teeth, 4 th ed.Copenhagen:Blackwell Munksgaard; 2011. P. 374.  Back to cited text no. 10
    
11.
Nikoui M, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population. III.Lateral luxations. Dent Traumatol 2003;19:280-5.  Back to cited text no. 11
    
12.
Ravn JJ, Rosen I. Hyppighed og fordeling of tramatiserede beskadigelser af taenderne hos kobenhavnske skoleborn 1967/68. Tandlaegeblader 1969;73:1-9.  Back to cited text no. 12
    
13.
Flores MT,Malmgren B, Andersson L,Andreasen JO, Bakland LK, Barnett F et al.Guidelines for management of traumatic dental injuries.III Primary teeth. Dent Traumatol 2007;23:196-202.  Back to cited text no. 13
    
14.
Needleman HL. The art and science of managing traumatic injuries to primary teeth. Dent Traumatol 2011;27:295-9.  Back to cited text no. 14
    
15.
F. M. Andreasen, Y. Zhijie, B. L.Thomsen, and P. K. Andersen, “Occurrence of pulp canal obliteration after luxation injuries inthe permanent dentition.,” Endodontics & Dental traumatology,vol. 3, no. 3, pp. 103-115, 1987.  Back to cited text no. 15
    
16.
F. M. Andreasen, “Pulpal healing after luxation injuries and root fracture in the permanent dentition,” Endodontics&Dental Traumatology, vol. 5, no. 3, pp. 111-131, 1989.  Back to cited text no. 16
    
17.
S. P. R.MacLeodandT.C.Rudd, “Updateonthemanagement of dentoalveolar trauma,” Current Opinion in Otolaryngology and Head and Neck Surgery, vol. 20, no. 4, pp. 318-324, 2012.  Back to cited text no. 17
    
18.
J. O. Andreasen, F. M. Andreasen, I. Mej`are, and M. Cvek,”Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics,” Dental Traumatology, vol. 20,no. 4, pp. 203-211, 2004.  Back to cited text no. 18
    
19.
S.Mazzoleni, G.Meschia, R. Cortesi et al., “In vitro comparison of the flexibility of different splint systems used in dental traumatology,” Dental Traumatology, vol. 26, no. 1, pp. 30-36,2010.  Back to cited text no. 19
    
20.
American Academy of Pediatric Dentistry. Guideline on management of Traumatic DENTAL Injuries:1.Fractures snd Luxations of Permanent teeth. Reference Manual 2018;39(6):401-19.  Back to cited text no. 20
    
21.
J. O. Andreasen, F. M. Andreasen, I. Mej”are, and M. Cvek,”Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics,” Dental Traumatology, vol. 20,no. 4, pp. 203-211, 2004.  Back to cited text no. 21
    
22.
T. von Arx, “Splinting of traumatized teeth with focus on adhesive techniques,” Journal of the California Dental Association,vol. 33, no. 5, pp. 409-414, 2005.  Back to cited text no. 22
    
23.
F. K. Kahabuka, W. Willemsen, M. Van’t Hof et al., “Initial treatment of traumatic dental injuries by dental practitioners/‘Endodontics & Dental Traumatology, vol. 14, no. 5, pp. 206-209,1998.  Back to cited text no. 23
    
24.
Ravn JJ. Follow-up study of permanent incisors with enamel fractures as a result of an acute trauma. Scand J Dent Res 1981;89:213-217.  Back to cited text no. 24
    
25.
S. Sapir and J. Shapira, “Decoronation for the management of an ankylosed young permanent tooth,” Dental Traumatology, vol.24, no. 1, pp. 131-135, 2008.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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