Brazilian Journal of Dental Traumatology (2010) 2(1): 17-21 2010 Sociedade Brasileira de Traumatologia Dentria a ISSN 2175-6155 http://www.sbtd.org.

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A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA Rosana Belchior Miranda1 , Marlia Fagury Videira Marceliano-Alves2 , Marcelo Rolla de Souza3 , Sandra Rivera Fidel4 and Rivail Antonio Srgio Fidel5 e
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 being associated with a complex oral traumatism. The prognosis depends on a good diagnosis and an appropriate treatment plan. This study presents a clinical case of a 15-year-old male, who had an accident during a soccer match. The trauma affected three teeth, their periodontal supports and 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 the suture of gingival tissue laceration. The patient was designated to Orthodontics for extrusion of the #21 tooth, which was essential to endodontic and restorative treatment. Pulp sensitivity of #11 and #12 teeth was tested for 7 months after trauma resulting in negative response. This condition led to endodontic indication to both of them. Sixteen months after the trauma, periapical radiograph showed a radiolucent image limited around the root apex of the #21 tooth that was, then, submitted to periradicular surgery. At 4 years follow-up, the area seemed healthy and the periapical radiograph 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.br 1 DDS, MSc, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil. 2 DDS, MS, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil. 3 DDS, MS, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil. 4 DDs, MSc, PhD, Department of Integrated Clinical Procedures (Proclin), State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil. 5 DDs, MSc, PhD, Endodontics Department, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

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A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA

INTRODUCTION Oro-facial injuries are commonly result from assaults, accidents with various means of transport, falls or during sports-related activities [2, 9, 23]. They constitute frequent urgency situations at dental offices. Dental traumatic injury may include from enamel fracture to total tooth loss. Predominantly, this type of trauma is seen especially in growing male school-age individuals [4, 6, 19, 21]. The injuries that involve front teeth may result in unfavorable functional and aesthetical effects, cause painful sintomatology and directly affect self-esteem [4, 6, 14]. Enamel and dentin fractures without pulpar exposure have favorable prognosis, even in cases of late treatment; however, dental care is required for evaluation, treatment and proservation of the case. Coronary fracture with pulp exposure, concussion, subluxation and intrusive luxation are regarded as mild-severity injuries, but they require immediate care [2, 5, 6, 9]. Avulsion, root fracture and alveolar fracture are regarded as more serious conditions, and must also receive prompt care [3, 9, 16]. Intrusive luxation means the axial displacement of the tooth inside the socket [1, 3, 7]. Traumatic intrusion represents 0.3 to 2% of the traumas affecting the permanent teeth [9, 11]. Due to the nature of this injury, with damage to gum tissue, periodontal ligament, alveolar bone wall and pulp, this is the scenario for a series of complications, including loss of gingival attachment, marginal bone loss, root resorption, ankylosis, pulp necrosis and paralysis of root formation in immature teeth [6]. At the moment of the impact, the periodontal ligament is compressed against the alveolar bone wall, fiber cutting occurs, as well as bone wall fracture and section of the neurovascular bundle, which results in pulp necrosis. In addition to the mechanical trauma, an intruded tooth may be contaminated by oral bacteria, with consequent risk of infection. Andreasen & Andreasen [6, 8] consider that the cure for trauma by intrusion is complex, resulting in complications in the cicatrization process. The authors also report that intruded teeth with incomplete root development usually re-erupt spontaneously, which could also occur to those with complete root formation, but it could take months, thus allowing a root resorption process. Therefore, orthodontic extrusion was indicated, enabling the endodontic treatment after coronary exposure [13]. This work aimed at reporting a clinical case of dental trauma with multidisciplinary treatment, performed at the Santos-Dumont Dental Clinic of Brazilian Air Force. CASE REPORT A 15-year-old Caucasian male came to the Santos-Dumont Dental Clinic of Brazilian Air Force (Rio de Janeiro, RJ, Brazil) in an urgency

condition because of a collision during a soccer match. The situation involved his maxillaries left (#21) and right (#11) central incisors and the maxillary right lateral incisor (#12). After carefully cleaning and sewing of gingival laceration at that area (black braided silk 4.0 a Ethicon Johnson & Johnson, So Paulo, Brazil), it was possible to evaluate the extension of the traumatism. The clinical examination showed that all the involved teeth had their crowns fractured without pulp exposure. Moreover, the #11 and #12 teeth showed mobility and did not demonstrate sensitivity to a cold test with refrigerant gas (Endo-Frost Roeko/Langenau Germany) such as the #21 tooth. The periodontal injury consisted of subluxation of #11 and #12 teeth and a severe intrusion of the #21 tooth, revealed by radiographic examination (Figure 1).

Figure 1 Panoramic radiographic examination.

Orthodontic wire has been used as a semi-rigid contention to settle the teeth (Figure 2). Two days later the splint was removed from the #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 the light-curing resin restorations were immediately performed to make aesthetics better and to protect the dentin-pulp complex. Semi-rigid contention was established for three weeks. At that moment, the patient began an orthodontic treatment to get the #21 tooth extrusion in order to bring it back to its original position (Figure 3). Six months later, the orthodontic appliance was removed and the #21 tooth endodontic treatment was carried out.

Brazilian Journal of Dental Traumatology, Vol. 2(1), 2010

ROSANA B. MIRANDA, MAR F. V. MARCELIANO-ALVES, MARCELO R. DE SOUZA, SANDRA R. FIDEL and RIVAIL A. S. FIDEL ILIA

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The perirradicular surgery was planned for this area and consisted of apical lesion curettage, apicectomy and retrograde filling with mineral trioxide aggregate (ProRoot 2 MTA Dentsply, USA) (Figure 6).

a)

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

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

a)

b)

Figure 6 a) periapical lesion removed by curettage; b) surgical bone site showing the #21 tooth apicectomy.

Six months after surgery, the patient was in excellent condition with neither symptom nor signal of any problem. Periapical radiograph suggested bone formation (Figure 7). Despite of the extensive surgical area, it was interesting to notice that there was not #22 tooth involvement such as revealed by a positive response to sensitivity pulp test. The histopathological test confirmed the diagnosis hypothesis of a periapical cystic lesion.

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

a)

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

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

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

Figure 5 Periapical radiograph 6 months after the #21 tooth endodontic retreatment showing a radiolucent image around its root apex.

Figure 8 Periapical radiograph at 4 years follow-up.

Brazilian Journal of Dental Traumatology, Vol. 2(1), 2010

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A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA

DISCUSSION The consequences of dental trauma in permanent teeth may be as follows: change of color, mobility, pulp necrosis, bone and dental resorptions which can occur by lack of immediate treatment or individual prognosis of the case [1, 3, 22, 12]. According to Andreasen, Bakland, Matras and Andreasen [9], the frequency of injuries by intrusive luxation is low (1.9%), but the treatment is complex. Dentinal protection was recommended in case of intrusion-related crown fracture, which was first performed in the case reported, as the exposed dentin may allow bacterial invasion. Besides, the aesthetical recovery allowed that the patient returned to his normal activities. The most common complication of intrusive luxation is pulp necrosis, due to ischemic changes, probably because of compression of the neurovascular bundle [1, 3, 10, 20]. As soon as the dental repositioning was achieved, the endodontic treatment was executed; however, there was still apical resorption and further development of the periradicular lesion. According to Andreasen & Andreasen [8], the chosen treatment for the repositioning must be the orthodontic extrusion, so that the crown is exposed as soon as possible, thus enabling the endodontic treatment, which is a means of preventing external root resorption that occurs, according to the same authors, around 3 weeks after. In this case, the crown was exposed only within six months of traction. Considering the severity of the intrusive luxation, there must have been damage to the periodontal membrane and the root surface, according to studies by several authors [1, 3, 10, 17]. The authors suggest a 5-year follow up period, due to the risk of further complications during the cicatrization process, such as resorption 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 cure prognosis. Therefore, in the case presented, the surgery was planned in order to perform curettage of the periradicular lesion, carry out an apicectomy and, also, refill with a bone-formation biocompatible and biostimulating material MTA [3, 25, 26]. In recent literature review, Torabinejad and Parirokh [27] reaffirmed that MTA was firstly recommended as root-end filling material and, by analyzing a great deal of studies, they emphasized the superior results for this material regarding the chemical and physical properties as well as the antibacterial activity, the excellent sealing ability and biocompatibility. The literature shows that long-term follow up of traumatized patients is fundamental [7, 8, 18]. Such fact was evident in the case presented, as #21 tooth was certainly preserved due to regular follow up of the patient for 18 months, which allowed the interventions to occur

at those very moments when the changes were observed. Although the patient 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 in the emergency service is high, and that it is extremely important to divulge the preventive and educative approach on dental traumas, especially in educational institutions, raising the professionals awareness on the issue, since urgency attitudes at the accident site may improve 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 to the trauma, as well as the long-term proservation are extremely important for the prognosis and maintenance of the tooth in the oral cavity. The long follow up of the patient and the interventions carried out at proper moments determined the success of the case presented. REFERENCES
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Brazilian Journal of Dental Traumatology, Vol. 2(1), 2010