luxation

Luxation injuries

By: Francis Prathyusha,MscD Endo 2nd yr.University Of The East

Traumatic injuries -3

Introduction Luxation injuries are injuries that

range from a mild blow to severe forms that either force the tooth into alveolar socket or partially dislocate it from the alveolar socket.

Incidence of these injuries is about 17%

Andersean Fm. ‘ Pulpal healing after luxation injuries and root fractures in the permanent dentition .’ Endodon Dent Traumatol 5:111, 1989

Luxation injuries

Classification Concussion Subluxation Extrusive luxation Lateral luxation Intrusive luxation

Concussion The tooth is sensitive to percussion

only. There is no increase in mobility, and the

tooth has not been displaced. The pulp may respond normally to

testing, and no radiographic changes are found.

Principles and Practice Of ENDODONTICS THIRD EDITIONMAHMOUD TORABINEJAD, DMD, M5D, PhD

Subluxation Subluxation injuries include teeth that are

sensitive to percussion and also have increased mobility.

Often sulcular bleeding is present, indicating vessel damage and tearing of the periodontal ligament. No displacement is found, and the pulp may respond normally to testing.

Radiographic findings are unremarkable

Principles and Practice Of ENDODONTICS THIRD EDITIONMAHMOUD TORABINEJAD, DMD, M5D, PhD

Examination and Diagnosis Concussion injuries generally respond to pulp

testing. Because the injury is less severe, pulpal blood supply is more likely to return to normal.

Teeth in the subluxation injury group also tend to retain or recover pulpal responsiveness but less predictably than teeth with concussion injuries.

In both cases, an immature tooth with an open apex has a better prognosis

Principles and Practice Of ENDODONTICS THIRD EDITIONMAHMOUD TORABINEJAD, DMD, M5D, PhD

Treatment of Luxation Injuries Concussion : No immediate treatment is

necessary. The patient should allow the tooth to "rest" (avoid biting) until sensitivity has subsided. Pulp status is monitored.

Subluxations : may likewise require no treatment unless mobility is moderate; if mobility is graded 2, then stabilization is done.

Management of subluxation injury in a thumb-sucking child: a case report Berna Celik, Zafer C. Cehreli Department of

Pediatric Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey

Dental Traumatology 2008; 24: e20–e23; doi: 10.1111/j.1600-9657.2008.00590.x

Custom trauma splintClinical appearance of the subluxated incisor.

View of the mouth 6 months after therapy. Due to cessation of the thumb-sucking habit, the open-bite has closed spontaneously.

Radiograph of the tooth, demonstrating favorable healing.

Extrusive luxation

These teeth have been partially displaced from the socket along the long axis. Such extruded teeth have greatly increased

mobility, and radiographs show displacement. The pulp usually does not respond to testing.

Principles and Practice Of ENDODONTICS THIRD EDITIONMAHMOUD TORABINEJAD, DMD, M5D, PhD

Clinical and radiographic features of extrusive luxation. The standard bisecting angle periapical radiographic technique is more useful than a steep occlusal exposure in revealing axial displacement. From ANDREASEN & ANDREASEN (1) 1985.

Lateral luxation Trauma has displaced the tooth lingually,

buccally, mesially, or distally, that is, out of its normal position away from its long axis.

If the apex has been translocated during the displacement, the tooth may be quite firm.

Percussion sensitivity may or may not be present with a metallic sound if the tooth is firm, indicating that the root has been forced into the alveolar bone.

Principles and Practice Of ENDODONTICS THIRD EDITIONMAHMOUD TORABINEJAD, DMD, M5D, PhD

Clinical and radiographic features of lateral luxation. The steepocclusal radiographic exposure or an eccentric periapical bisecting angle exposure are more useful than an orthoradial bisecting technique in revealing lateral displacement. From ANDREASEN & ANDREASEN.

Intrusive luxation

Teeth are forced into their sockets in an axial (apical) direction, at times to the point of being buried and not visible.

They have decreased mobility and resemble ankylosis

Principles and Practice Of ENDODONTICS THIRD EDITIONMAHMOUD TORABINEJAD, DMD, M5D, PhD

Examination and Diagnosis

Extrusive, lateral, and intrusive injuries involve more displacement and therefore more damage to apical vessels and nerves. Therefore pulp responses in teeth with extrusive, lateral, and intrusive luxations are often absent.

These pulps often do not recover responsiveness even if the pulp is vital (has blood supply), because sensory nerves are permanently damaged.

Exceptions are immature teeth with wide-open apices; these teeth often regain or retain pulp vitality (responsiveness) even after severe injuries .

Pulp testing Carbon dioxide ice or the EPT is used to test An initial lack of response is neither unusual, nor

is a high reading on the pulp tester. Retesting is done in 4 to 6 weeks; the results are recorded and compared.

If the pulp responds in both instances, the prognosis for pulp survival is good. A pulp response that is absent initially and present at the second visit indicates a probable recovery of vitality, although cases of subsequent reversals have been noted.' If the pulp fails to respond both times, the prognosis is questionable and the pulp status uncertain.

Pulp testing In the absence of other findings indicating

pulp necrosis, the tooth is retested in 3 to 4 months.

Continued lack of response may indicate pulp necrosis by infarct, but lack of response may not be enough evidence to make a diagnosis of pulp necrosis. That is, the pulp may permanently lose sensory nerve supply but retain its blood supply.

After a period of time, the pulp often responds to testing if it recovers.

Radiographic evaluation The initial radiograph made after the

injury will not disclose the pulp condition.

The radiographs are taken in the intervals and used for pulp testing

Evidence of resorption, both internal and external, and periradicular bony changes is sought

Radiographic evaluation Resorptive changes, particularly

external changes, may occur soon after injury; if no attempt is made to arrest the destructive process, much of the root may be rapidly lost.

Inflammatory resorption can be intercepted by timely endodontic intervention.

Pulp space calcification Pulp space calcification or obliteration is

a common finding after luxation injuries." Also called calcific metamorphosis and does not require root canal treatment, except when other signs and symptoms indicate pulp necrosis.

Crown color changes Pulp injury may cause discoloration, even after

only a few days. Initial changes tend to be pink. Subsequently, if the pulp does not recover and

becomes necrotic, there may be a grayish darkening of the crown, often accompanied by a loss in translucency. Also, color changes may take place owing to increased calcific metamorphosis. Such color changes are likely to be yellow to brown and do not indicate pulp pathosis.

Finally, discoloration may be reversed. This usually happens relatively soon after the injury and indicates that the pulp is vital.

Extrusive and lateral luxation injuries require repositioning and splinting . The length of time needed for splinting varies with the severity of injury.

Extrusions may need only 2 to 3 weeks, whereas luxations that involve bony fractures need up to 8 weeks.'

Root canal treatment is indicated for teeth with a diagnosis of irreversible pulpitis or pulp necrosis.

Treatment of Luxation Injuries

Treatment of extrusive luxation. The extruded tooth should be gently repositioned using axial finger pressure on the incisal edge and the toothsplinted.

This 17-year-old man has extruded the left central incisor and avulsed the lateral incisor, which could not be retrieved.

Mobility and percussion test

Diagnosis and treatment of extrusive luxation

Case report

Sensibility testing & radiographic examination

Repositioning

Case report

Applying splinting material

Polishing the splint

Case report

The finished splint

Suturing the gingival wound

Case report

Treatment principles for lateral luxation: repositioning and splinting.

This 23-year-old man suffered a lateralluxation of the left central incisor.

Diagnosis and treatment of lateral luxation

Percussion test

Case report

Mobility and sensibility testing

Radiographic examination

Case report

Anesthesia

Repositioning

Case report

Verifying repositioning andsplinting with the acid-etchtechnique

Preparing the splinting material

Case report

Applying the splinting material

Three weeks after injury

Case report

Splint removal

Six months after injury

Case report

Treatment of intrusive luxation Treatment of intrusive luxation injuries

depends on root maturity. If the tooth is incompletely formed with an open apex, it may re-erupt.

If it is fully developed, active extrusion will be necessary soon after the injury, usually by an orthodontic appliance.

In extreme cases of intrusion, in which the tooth has been totally embedded into the alveolus, surgical repositioning may be necessary.

Surgical repositioning should, however, be only partial and should be supplemented with orthodontic extrusion to reduce the risk of marginal bone loss and ankylosis

Root canal treatment is indicated for intruded teeth with the exception of those with immature roots, in which case the pulp may revascularize

The patient GCSA, aged 15 years, of female gender, suffered a bicycle accident that gave rise to intrusive luxation of the right maxillary central incisor

Intrusive luxation: a case reportde Alencar AHG, Lustosa-Pereira A, de Sousa HA, Figueiredo JH.Intrusive luxation: a case report.Dental Traumatology 2007; doi: 10.1111/j.1600-9657.2006.00461.x

Intrusive luxation of the right maxillary central incisor.

Right maxillary central incisor after surgical exposure ofthe crown.

Radiograph for odontometry of the right maxillary central incisor still intruded

Radiograph of the right maxillary central incisor afterorthodontic repositioning and placement of calcium hydroxide based root canal dressing.

Right maxillary central incisor after orthodontic repositioning

Radiograph of the right maxillary central incisor afterroot canal obturation.

Right maxillary central incisor after completion ofendodontic treatment.

Follow-up radiograph of the right maxillary central incisor at 30 months after root canal obturation

Primary Teeth Concussion and subluxation injuries

require no treatment. Pulpal evaluation is limited to radiographic

and clinical observation. Persistent crown discoloration usually indicates pulp necrosis, necessitating either root canal treatment or extraction. ' Discolored primary teeth may return to normal color, probably indicating recovery of the pulp.

Primary Teeth Calcitic metamorphosis is common after

luxation injuries. This changes the primary crown to a darker yellow color, which is not pathosis and so requires no treatment.

Teeth with lateral and extrusive luxations may be left untreated, or the tooth may be extracted, depending on the severity of injury. Teeth with intrusive luxations should be carefully evaluated to determine the direction of intrusion. Radiographs provide valuable information. If the intruded

Primary Teeth Intruded tooth appears foreshortened on the

film, the apex is oriented toward the x-ray cone. Therefore these teeth should present no danger to the permanent successor and may be left to re-erupt.

If the tooth appears elongated, the apex is oriented toward the permanent successor and may pose a risk to the permanent tooth bud. The tooth should be carefully extracted if it impinges on the permanent successor. Also evaluated is the symmetry of the permanent tooth buds.'

Prognosis of pulp after luxation injuries • Teeth with incomplete root formation : Allow spontaneous

repositioning to take place. If no movement is noted with in 3 weeks, recommended rapid orthodontic repositioning.

• Teeth with complete root formation : The tooth should be repositioned either orthodontically or surgically, as soon as possible. The pulp will likely be necrotic and root canal treatment using a temporary filling with calcium hydroxide is recommended to retain the tooth.

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