Hindawi

Case Reports in Dentistry

Volume 2021, Article ID 5540860, 6 pages
https://doi.org/10.1155/2021/5540860

Case Report
Management and Follow-Up of Complicated Crown
Fractures with Intrusive Luxation of Maxillary Incisors in an
8-Year-Old Boy

Niusha Abazarian,1 Shabnam Milani,2 Moahammad Hassan Hamrah,3

and Marzieh Salehi Shahrabi 2
1
Department of Pediatric Dentistry, Dental School, AJA University of Medical Sciences, Tehran, Iran
2
Department of Pediatric Dentistry, Tehran University of Medical Sciences, Tehran, Iran
3
Department of Pediatric Dentistry, School of Dentistry, Tehran University of Medical Sciences Tehran, Iran

Correspondence should be addressed to Marzieh Salehi Shahrabi; salehipegah7@gmail.com

Received 27 February 2021; Revised 14 April 2021; Accepted 13 May 2021; Published 24 May 2021

Academic Editor: Andrea Scribante

Copyright © 2021 Niusha Abazarian et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Intrusive luxation is a severe form of dental injury which causes damage to the pulp and supporting structures of a tooth because of
its dislocation into the alveolar process. This paper shows the case of the reeruption of maxillary incisors accompanied by
complicated crown fractures after 3 months. An 8-year-old boy patient was referred to the Department of Pedodontic Dentistry
of Tehran University of Medical Science, Tehran, Iran, 18 hours after a fall at school. Clinical and radiographic examinations
revealed intrusive luxation of both incisors with complicated crown fractures. Cervical pulpotomy is the treatment of choice for
traumatized immature intruded teeth with pulp exposure. Two months later, the right central incisor teeth reerupted to a
normal position and the final aesthetic restorations were done. The left central incisor was spontaneously repositioned with
external root resorption, and the team decided to use interim medication (calcium hydroxide) in the root canal for stopping the
process of resorption, and by the 9-month follow-up, the process of resorption had been stopped. An MTA plug was placed into
the canal, and the final esthetic restorations were done.

1. Introduction pulp. Healing subsequent to trauma is complex. Complica-

tions include pulp necrosis, inflammatory root resorption,
The most frequent traumatic dental injuries involving per- dentoalveolar ankylosis, loss of marginal bone support, calci-
manent teeth are complicated and uncomplicated crown fication of pulp tissue, paralysis or disturbance of root devel-
fractures, and the most affected teeth are maxillary central opment, and gingival retraction [1, 4]. Intrusive luxations are
incisors (93.3%) especially in children [1]. The most severe associated with a high risk of complications during healing,
form of traumatic dental injury is intrusive luxation that including pulpal necrosis and calcification, external inflam-
accounts for 15–61% of traumas in permanent teeth and is matory resorption, replacement resorption, gingival retrac-
defined as apical displacement of the tooth in its socket. tion, and marginal bone loss [4]. The incidence of pulp
The etiological factors include falling, bicycle injury, sports necrosis for intruded teeth with open apex is significantly
accidents, and fights [2, 3]. lower compared to closed apex, and it occurs between 63%
Intrusive luxation of permanent teeth is a rare dental and 68% in open apex and 100% for teeth with closed apex
injury when compared with other types of luxation injuries. [1]. Depending on the severity of intrusion, the frequency
It comprises of 3% of all traumatic injuries in the permanent of replacement resorption in intruded incisors ranges from
teeth [1]. The displacement results in the damage to the alve- 5% to 31% [2, 3] and appears to be more in mature than in
olar bone, the periodontal ligament, the cementum, and the immature teeth [5]. Although 97% of all inflammatory
2 Case Reports in Dentistry

Table 1: Patient characteristics.

Clinical examination Clinical examination

Age Sex Chief complaint Radiographic examination
(extraoral examination) (intraoral examination)
Abrasion on the skin of the chin Complicated crown fracture of An intact periodontal
8 Trauma of the central
inflammation and bleeding of the the central incisors with no ligament space, incomplete
years Male incisors following a fall
labial gingival of the central mobility and percussive metallic root formation, no root
old at school 18 hours ago
incisors sound fracture

resorption are arrested after long-term calcium hydroxide

therapy, there is no effective treatment for replacement
resorption [1].
There are numerous ways to manage complicated crown
fractures, such as direct pulp capping, partial pulpotomy, cer-
vical pulpotomy, or pulpectomy. Furthermore, the treatment
option for intruded teeth up to 7 mm for open apex is spon-
taneous repositioning [5].
Cervical pulpotomy is the treatment of choice for trau-
matized immature intruded teeth with pulp exposure. It
allows the development of the roots to continue, with apical
closing and strengthening of the root structure [6].
The present case report describes the management and Figure 1: Intraoral examinations.
follow-ups of traumatized immature intruded teeth with
complicated crown fractures.

2. Case Presentation
An 8-year-old boy patient was referred to the Department of
Pedodontic Dentistry of Tehran University of Medical Sci-
ence, Tehran, Iran, with the chief complaint being trauma
of the central incisors following a fall at school 18 hours
ago. The general medical, dental, and traumatic incident his-
tories were recorded. There was no systemic disease history.
Extraoral examination revealed abrasion on the skin of the
chin and inflammation and bleeding of the labial gingival of
the central incisors (Table 1). Intraoral examination revealed
complicated crown fracture of the central incisors with no
mobility and percussive metallic sound, indicating intrusion
[1] (Figure 1).
Periapical radiographic examination showed an intact
periodontal ligament space, incomplete root formation of
both central incisors, and no root fracture (Figure 2).
The periapical radiographies were taken using Xgenus
(de Gotzen S.r.l device, distributed by Satelec-Acteon Group, Figure 2: Radiographic examinations.
Italy).
Cervical pulpotomy using white mineral trioxide aggre- Follow-up after 4 weeks showed left central incisor per-
gate (BioMTA, Seoul, Republic of Korea) was done for both cussion with spontaneous eruption, and the right central
incisors after under local anesthesia and rubber dam isola- incisor percussion was metallic sound with no signs and
tion; all coronal pulp tissues were gently removed by using symptoms. Radiographic evaluations have demonstrated a
a high-speed sterile round diamond bur (Dentsply Maillefer, PDL widening in the middle third of the root in both central
Tulsa, OK, USA) under water cooling. Hemorrhage was con- incisors (follow-up after 1 month) (Figure 4).
trolled with sterile cotton pellets and sterile saline solution to After 2 months of follow-up, the left center incisor was
avoid clot formation. When pulpal bleeding stopped within spontaneously repositioned with external root resorption
3 min, MTA powder was mixed with distilled water accord- and had a sensitive percussion. And the right central incisor
ing to the recommended consistency and placed without with no signs and symptoms showed normal percussion and
any pressure to cover the exposed pulps. A moist cotton pel- mobility with a normal radiography, and so, it was decided to
let was placed on the MTA, and the cavity was sealed tempo- do a composite buildup (Figure 5).
rarily with RMGI (Fuji IX, GC Corporation, Tokyo, Japan) Treatment used to stop the external resorption of the left
(Table 2 and Figure 3). central incisor was irrigation with sodium hypochlorite
Case Reports in Dentistry 3

Table 2: Clinical passages.

Phase
Treatment steps
number
Under local anesthesia and rubber dam isolation, all coronal pulp tissues were gently removed by using a high-speed sterile
1
round diamond bur (Dentsply Maillefer, Tulsa, OK, USA) under water cooling.
2 Hemorrhage was controlled with sterile cotton pellets and sterile saline solution to avoid clot formation.
When pulpal bleeding stopped within 3 min, MTA powder was mixed with distilled water according to the recommended
3
consistency and placed without any pressure to cover the exposed pulps.
A moist cotton pellet was placed on the MTA, and the cavity was sealed temporarily with RMGI (Fuji IX, GC Corporation,
4
Tokyo, Japan).

Figure 3: Cervical pulpotomy white MTA for both incisors.

Figure 5: Follow-up after 8 weeks.

Figure 4: Follow-up after 4 weeks.

(Beyond Technology Corp., Beijing, China) and saline. The

CaOH (Prevest Denpro, Golchai, Iran) was positioned within Figure 6: Calcium hydroxide was applied as intracanal medicament
the canal and dressed with RMGI (Fuji II LC, GC, Tokyo, to stop the external resorption.
Japan) (Figure 6).
After 3 months, CaOH (Prevest Denpro, Golchai, Iran)
was replaced. At the 9-month follow-up, the resorption pro- composite (Filtek Z350 XT, 3 M ESPE, St. Paul, MN, USA)
cess had stopped, and an MTA (BioMTA, Seoul, Republic of buildup, was performed (Figures 7(a) and 7(b)).
Korea) plug was placed in the canal and dressed with RMGI At the 22-month recall, the teeth were asymptomatic and
(Fuji II LC, GC, Tokyo, Japan). After one week, obturation, showed no signs of resorption, clinically and radiographically
done with gutta-percha (reoko, Langenau, Germany) and (Figures 8(a) and 8(b)).
4 Case Reports in Dentistry

(a) (b)

Figure 7: (a) MTA apical plug of 4-5 mm thickness and final obturation. (b) Final restoration of the tooth.

(a) (b)

Figure 8: (a) Follow-up after 22 months. (b) Radiography after 22-month follow-up.

Table 3: Clinical procedures.

Phase number Treatment steps

First session Cervical pulpotomy white MTA for both incisors
(i) Left central incisor percussion with spontaneous eruption
(ii) Right central incisor percussion was metallic sound with no signs and symptoms
Follow-up after 4 weeks
(iii) Radiographic evaluations have demonstrated a PDL widening in the middle third of the root in both central
incisors
(i) The left center incisor was spontaneously repositioned with external root resorption and had a sensitive
percussion, and calcium hydroxide was applied as intracanal medicament
Follow-up after 8 weeks
(ii) The right central incisor with no signs and symptoms showed normal percussion and mobility with a
normal radiography
Follow-up after 36 weeks The resorption process had stopped, and an MTA plug was placed in the canal and dressed with RMGI.
Follow-up after 37 weeks Obturation, done with gutta-percha and composite buildup, was performed
Follow-up after 22 months The teeth were asymptomatic and showed no signs of resorption, clinically and radiographically.
Case Reports in Dentistry 5

The patient has been followed for the last 22 months dressing to allow the healing should be kept for 6–9 months
showing the success of the treatment (Table 3). [16].
The long-term use of calcium hydroxide has some draw-
backs. The treatment requires multiple appointments and
3. Discussion takes anywhere from 3 to 18 months [17, 18]. It demands
high cooperation and motivation from the patient. In addi-
Complicated crown fractures are defined as fractures involv- tion, the long-term presence of calcium hydroxide in root
ing enamel and dentin with pulp exposure. These injuries canal space can increase the brittleness of the root dentin
produce changes in the exposed pulp tissues, and a biological and the risk of future cervical root fractures especially in open
and functional restoration represents an important clinical apex teeth [11]. In spite of these disadvantages, it is still
challenge [1]. the preferred treatment protocol due to its high success
Dental traumas may include numerous injuries, includ- rate [1, 11].
ing intrusion (33.5%), an associated crown fracture intrusion This case report shows that within the limitations of this
(60.5%), or a combination of intrusion and coronal or root study is a successful outcome. However, there were weak-
fractures (6%) [2]. In most cases, it affects only one tooth nesses on follow-up of the patient due to the COVID-19 pan-
(46.3%), followed by two teeth (32.4%) and three or more demic lockdown and delay in attending patient to hospital
teeth (21.3%) [7]. Most of the intruded teeth are displaced after injury.
from 1 to 8 mm into the alveolar bone by a traumatic
force [8]. 4. Conclusion
Intrusive luxation is a type of severe trauma that results in
injury to the tooth structure, cells and fibers of periodontal The findings in this case report suggest that calcium hydrox-
ligament, pulp tissue, and alveolar bone [9]. ide stops the inflammatory resorption with a high degree of
Intrusive luxation is associated with a high risk of compli- success.
cations during healing and considered as one of the most
difficult types of injury to treat as there are differing opinions
on what constitutes as treatment. It was previously believed
Conflicts of Interest
that the stage of development of the root was the determining The authors declare that they have no conflicts of interest.
factor for prognosis of intruded teeth [10]. Current dental
literature suggests different treatment approaches for the
management of intrusive luxation injuries including passive References
repositioning, allowing the tooth to reerupt, and active repo- [1] J. O. Andreasen, L. K. Bakland, R. C. Matras, and F. M.
sitioning, either surgically or by use of orthodontic appli- Andreasen, “Traumatic intrusion of permanent teeth. Part 1.
ances [2]. Miniscrews are effective orthodontic devices for An epidemiological study of 216 intruded permanent teeth,”
various orthodontic movements of the intruded teeth; it is Dental Traumatology, vol. 22, no. 2, pp. 83–89, 2006.
recommended for dental extrusion without involving other [2] J. O. Andreasen, F. M. Andreasen, and L. Andersson, Textbook
teeth, implant side effects, or gingival margin cosmetic dis- and color atlas of traumatic injuries to the teeth, John Wiley &
ability [11]. In case of intrusive luxation, the miniscrew- Sons, 2018.
assisted orthodontic repositioning has been proposed [11]. [3] V. Chacko and M. Pradhan, “Management of traumatically
In fact, orthodontic miniscrews demonstrated excellent intruded young permanent tooth with 40-month follow-up,”
mechanical properties and also with small diameters so they Australian Dental Journal, vol. 59, no. 2, pp. 240–244, 2014.
can be used also in hard to reach areas [12]. [4] J. M. Humphrey, D. J. Kenny, and E. J. Barret, “Clinical out-
Root resorption after an intrusion is a commonly occur- comes for permanent incisor luxations in a pediatric popula-
ring scar complication. Inflammatory root resorption and tion. I. Intrusions,” Dental traumatology, vol. 19, no. 5,
replacement root resorption are classified as invasive or pro- pp. 266–273, 2003.
gressive root resorption [11, 12]. External root resorption [5] A. W. Raut, V. Mantri, V. I. Shambharkar, and M. Mishra,
has been reported and cited to be between 28% and 66% “Management of complicated crown fracture by reattachment
[1, 13, 14]. Andreasen et al. reported a total incidence of using fiber post: minimal intervention approach,” Journal of
natural science, biology, and medicine, vol. 9, no. 1, pp. 93–
86% of external resorption (38% inflammatory, 24% surface,
96, 2018.
and 24% replacement resorption). They also found a higher
[6] A. Nosrat and S. Asgary, “Apexogenesis treatment with a new
incidence of resorption in teeth with closed apices (70%)
endodontic cement: a case report,” Journal of Endodontics,
than in those with open apices (58%) [1]. vol. 36, no. 5, pp. 912–914, 2010.
It has been shown that calcium hydroxide stops the [7] V. Faus-Matoses, M. Martínez-Viñarta, T. Alegre-Domingo,
inflammatory resorption with a high degree of success [15]. I. Faus-Matoses, and V. J. Faus-Llácer, “Treatment of multiple
Calcium hydroxide paste should be maintained in the root traumatized anterior teeth associated with an alveolar bone
canal for 1 to 6 months before obturation with gutta-percha fracture in a 20-year-old patient: a 3-year follow up,” Journal
points. In this case, we applied calcium hydroxide (Prevest of clinical and experimental dentistry, vol. 6, no. 4, 2014.
Denpro, Golchai, Iran) paste when the external root resorp- [8] R. F. Cunha, “Early treatment of an intruded primary tooth: a
tion has been started. After 9 months of follow-up, the case report,” The Journal of Clinical Pediatric Dentistry, vol. 25,
resorption process had been stopped. In support of this, no. 3, pp. 199–202, 2001.
6 Case Reports in Dentistry

[9] C. Y. Yu and P. V. Abbott, “Responses of the pulp, periradicu-

lar and soft tissues following trauma to the permanent teeth,”
Australian dental journal., vol. 61, pp. 39–58, 2016.
[10] A. L. C. S. D. Omena, I. A. Ferreira, C. L. Ramagem, K. M. S.
Moreira, I. Floriano, and J. C. Imparato, “Severe trauma in
young permanent tooth: a case report,” RGO-Revista Gaúcha
de Odontologia, vol. 68, 2020.
[11] R. F. Horliana, A. C. Horliana, A. D. Wuo, F. E. Perez, and
J. Abrão, “Dental extrusion with orthodontic miniscrew
anchorage: a case report describing a modified method,” Case
reports in dentistry, vol. 2015, Article ID 909314, 6 pages, 2015.
[12] M. F. Sfondrini, P. Gandini, R. Alcozer, P. K. Vallittu, and
A. Scribante, “Failure load and stress analysis of orthodontic
miniscrews with different transmucosal collar diameter,” Jour-
nal of the mechanical behavior of biomedical materials, vol. 87,
pp. 132–137, 2018.
[13] A. Rovira-Wilde, N. Longridge, and S. McKernon, “Manage-
ment of severe traumatic intrusion in the permanent denti-
tion,” BMJ Case Reports CP, vol. 14, no. 3, p. e235676, 2021.
[14] C. J. Pearce, “Recent developments in equine dentistry,” New
Zealand veterinary journal, vol. 68, no. 3, pp. 178–186, 2020.
[15] H. Al-Saffar and S. V. Stefanescu, “Management of non-vital
open apex in a lateral incisor using calcium hydroxide and
reverse GP cone cold lateral compaction in a general practice
setting,” Journal of Dental Research, vol. 2, no. 1, pp. 1–12,
2021.
[16] R. M. Darley, C. Fernandes e Silva, F. D. Costa, C. B. Xavier,
and F. F. Demarco, “Complications and sequelae of concus-
sion and subluxation in permanent teeth: a systematic review
and meta-analysis,” Dental traumatology, vol. 36, no. 6,
pp. 557–567, 2020.
[17] D. D. Müller, R. Bissinger, M. Reymus, K. Bücher, R. Hickel,
and J. Kühnisch, “Survival and complication analyses of
avulsed and replanted permanent teeth,” Scientific Reports,
vol. 10, no. 1, pp. 1–9, 2020.
[18] C. Bourguignon, N. Cohenca, E. Lauridsen et al., “Interna-
tional Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 1. Fractures and lux-
ations,” Dental Traumatology, vol. 36, no. 4, pp. 314–330,
2020.