A Novel Multidisciplinary Approach for the Treatment of an Intruded Immature Permanent Incisor

Luminex Clear Plastic post

Resident: Swan

Article Title: A Novel Multidisciplinary Approach for the Treatment of an Intruded Immature Permanent Incisor

Journal: Pediatric Dentistry

Volume (Number): 26:5, 2004

Major Topic: Treatment options for an intruded permanent incisor

Type of Article: Case Report

Overview of method of research: A 7 ½ yr old girl was referred to the Emergency Clinic at the Hadassah School of Dental Medicine in Jerusalem. She had fallen 3 days earlier and #9 was totally intruded (distance from incisal edge #9 to that of #8 was 6 mm). The tooth was slightly mobile and had an uncomplicated crown fracture. No alveolar bone fracture or root penetration into the floor of the nose was found. Root development classified as stage 5 according to Moorees.

Common sequelae after intrusive injury to an incisor include pulp necrosis, external or internal root resorption, partial or total pulp canal obliteration, marginal bone loss, disturbance to root development, and gingival recession. Options for treatment may include 1. Observation for spontaneous eruption, 2. Surgical crown uncovering, 3. Orthodontic extursion, 4. Partial surgical exposure followed by ortho extrusion.

Findings: Immediate treatment included 1) OHI, 2) chlorhexidine rinse, and 3) soft diet for one week. The tooth showed no signs of spontaneous re-eruption after two weeks, so they initiated orthodontic extrusion with a modified Hawley appliance. A week after starting extrusion, the tooth became percussion tender, mobile, and grayish in color—diagnosed as necrotic. The canal was debrided and filled with CaOH paste (Calxyl). Two weeks later, x-rays showed severe external inflammatory root resorption and marginal bone loss. Extrusion was continued for 5 weeks, retained for 2 more, then restored with and Odus celluloid crown (provisional crown form). Six months later, apexification was complete and the canal was obturated w/Gutta Percha. Two months later the final restoration was placed. The gutta percha was cleared to 3 mm below the CEJ, sealed with Vitrebond, composite was introduced into the canal, then a Luminex clear plastic post was bonded into place. The crown was restored again using an Odus crown form. After 5 years of follow up and full ortho treatment, #9 showed excellent results, no adverse reaction.

Key Points/Summary: The authors demonstrate a unique approach to treatment of an intruded immature permanent incisor. The most common problem after immature tooth intrusion is cervical root fracture due to the thin dentinal walls. In this case, after extrusion, the authors used a clear post and composite to strengthen the thin root. This technique reportedly achieves composite curing up to a depth of 11 mm.

Assessment of Article: Good report of a technique we should be aware of. My biggest question regarding the case was one they actually brought up themselves—would earlier RCT have prevented the severe external inflammatory resorption that occurred? They justified waiting for possible revascularization, due to the stage of root development.