It is generally agreed that for most luxation injuries,
with the exception of intrusive injuries in mature teeth,
endodontic therapy should be postponed until
additional signs of necrosis appear such as colour
change and radiographic changes, both in the tooth and
the surrounding bone.
Should the pulp become
necrotic and infected, treatment is dependent upon the
state of closure of the apex. If apical maturation is
complete, standard endodontic treatment is indicated.
Should apical development be incomplete, apexification
procedures utilizing calcium hydroxide
and/or MTA are indicated.
The first concern in the treatment of luxation injuries
should be the repair of the periodontium. Soft tissue
injuries and repositioning should be treated before
endodontic procedures are contemplated.
Endodontic treatment need not be considered for
concussion and subluxation injuries until there are
signs of pulp necrosis. However, judicious grinding may
be necessary to free the tooth from occlusion. Frequent
radiographic examinations and pulp sensibility testing
are needed during the follow-up period.
If the root is extruded, careful monitoring of the
tooth must be undertaken after repositioning and a
period of splinting of two weeks duration. In the event
that there has been a delay in repositioning the teeth,
gentle orthodontic treatment may be needed to
reposition them. Radiographic examination and pulp
sensibility testing should be carried out at regular
intervals such as: two weeks, one month, two months,
six months, 12 months and then on a yearly basis for a
number of years.
Endodontic therapy should be commenced immediately there is evidence of pulp
necrosis or root resorption. While immature teeth can
revascularize and can continue root development,
which can be seen radiographically, it is not prudent to
delay treatment in immature teeth that show any sign
of root resorption, as inflammatory root resorption can
occur very rapidly. A delay in treatment even for one
week can result in loss of substantial tooth structure. In
these teeth, pulp extirpation and root filling after
calcium hydroxide or corticosteroid/antibiotic therapy
is the treatment of choice. In mature teeth, endodontic
therapy should be undertaken where there is clinical
and/or radiographic evidence of pulp necrosis and
infection, or root resorption. Continued lack of
reaction to pulp sensibility testing is usually indicative
of pulp necrosis, unless there is radiographic evidence
of ongoing calcific changes in the root canal system.
Where a tooth has been laterally luxated, it should be
repositioned without delay. Again, endodontic therapy
is carried out only when there are signs of pulp necrosis
or root resorption. Lateral luxation does not occur
without fracture of the alveolar socket. Immediate
repositioning, with forceps if necessary, and splinting
is therefore recommended. Splinting should be of
four weeks duration to allow the fractured bone to
heal.
Treatment of intruded teeth can be a challenge. Pulp
necrosis almost invariably occurs in intruded mature
teeth and treatment can complicated by the fact
that most intruded teeth are also associated with crown
fractures.
Subsequent re-eruption, if it occurs, may be
very slow during which time root resorption may
become advanced. Delayed repositioning leaves roots in
intimate contact with bone and this influences the onset
of replacement resorption. Thus, mature teeth should
be repositioned as soon as possible and the pulps
removed immediately, or as soon as possible once the
soft tissues have healed sufficiently to do so, to help
prevent the onset of inflammatory root resorption.
22,74
Repositioning intruded teeth is a priority and can
occur through spontaneous re-eruption or it may
require surgical or orthodontic repositioning. Surgical
repositioning or orthodontic repositioning is the
treatment of choice for mature teeth in adults (>17 years
of age).
A recent review found no significant
difference in healing between surgical or orthodontic
repositioning of permanent intruded teeth.
Surgical repositioning is preferred where there is complete
intrusion and gingival healing may prevent re-eruption
or complicate orthodontic repositioning. A surgical
technique may be more practical for multiple intrusions
where orthodontic anchorage may be an issue. Care
must be taken in repositioning these teeth to ensure that
the hard tissues are brought down with the tooth and
that the soft tissues are sutured into place if necessary.
While orthodontic extrusion has been advocated, it is
not always possible as the teeth are often wedged firmly
into the bone and attempts to extrude the tooth can
lead to intrusion of adjacent teeth. Each situation has to
be assessed on its merits and on the state of
development of the tooth. Mature teeth that are firmly
wedged into the alveolus should be immediately
repositioned surgically. In mature teeth, urgent
endodontic management should be commenced as soon
as practical following repositioning.
Intruded teeth with open apices are more likely to
erupt spontaneously and less likely to develop problems
of an endodontic origin. As immature intruded teeth
can spontaneously reposition themselves in the arch
and significantly better healing occurs when this
happens, it has been suggested that treatment be
delayed for these teeth.
However, if spontaneous repositioning does not appear to be occurring quickly,
immature teeth can be brought down by orthodontic or
surgical means as soon as possible after trauma. There
is an argument for surgically disimpacting these
intruded immature teeth from the alveolus to assist
with re-eruption. Regular radiographic follow-up at
two weeks, one month, two months, six months and
yearly is essential for these teeth as root resorption can
occur rapidly in immature teeth.
Should any resorption be detected, pulpectomy and treatment with calcium
hydroxide or a corticosteroid/antibiotic paste prior to
root filling procedures should be urgently carried out.
Surgical exposure of the intruded immature
teeth to permit endodontic therapy has been proposed
to avoid delay in endodontic treatment and the
development of inflammatory root resorption.