Successful treatment of laterally luxated teeth with traumatic occlusion in adolescent patient by single arch fixed orthodontic therapy: A case-report

Mohammad Kamran Khan; Mahendra Kumar Jindal

doi:10.4103/SDJ.SDJ_19_22

CASE REPORTS

Year : 2022 | Volume : 6 | Issue : 2 | Page : 87-93

Successful treatment of laterally luxated teeth with traumatic occlusion in adolescent patient by single arch fixed orthodontic therapy: A case-report

Mohammad Kamran Khan¹, Mahendra Kumar Jindal²
¹ Private Pediatric Dental Practice, Aligarh, Uttar Pradesh, India
² Department of Pediatric and Preventive Dentistry, Aligarh Muslim University, Aligarh, India

Date of Submission	07-Mar-2022
Date of Decision	07-Apr-2022
Date of Acceptance	20-Apr-2022
Date of Web Publication	12-Jul-2022

Correspondence Address:
Mohammad Kamran Khan
Hamdard Nagar-A, Civil Line, Aligarh, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_19_22

Abstract

Background: Luxation dental injuries are considered a severe form of traumatic dental injury (TDI) due to several factors. International association of dental traumatology (IADT) has suggested various treatment approaches for suitable clinical conditions of the injured tooth and other factors. Case Report: The current article presents a case report of the successful and effective clinical management of luxated permanent incisors in an adolescent patient’s traumatic occlusion (dental trauma-induced crossbite relation) by employing single-arch fixed orthodontic therapy with light forces using Nickel-Titanium (NiTi) archwire. Conclusion: Lateral luxation injuries with traumatic occlusion (locked position of involved teeth) can be effectively repositioned by orthodontic traction using light orthodontic forces of NiTi archwire, particularly in patients who seek dental treatment after a few days of a TDI event.

Keywords: Dental trauma, fixed orthodontic therapy, lateral luxation, minimally-invasive dentistry, orthodontic traction, traumatic-occlusion

How to cite this article:
Khan MK, Jindal MK. Successful treatment of laterally luxated teeth with traumatic occlusion in adolescent patient by single arch fixed orthodontic therapy: A case-report. Sci Dent J 2022;6:87-93

How to cite this URL:
Khan MK, Jindal MK. Successful treatment of laterally luxated teeth with traumatic occlusion in adolescent patient by single arch fixed orthodontic therapy: A case-report. Sci Dent J [serial online] 2022 [cited 2023 Mar 20];6:87-93. Available from: https://www.scidentj.com/text.asp?2022/6/2/87/350757

Background

Oral traumatic injuries comprise about 5% of all bodily injuries, of which traumatic dental injuries account for 95% of all oral traumatic injuries.^[1],[2],[3] Traumatic dental injuries (TDIs) are not life-threatening emergency conditions. Because of this, they might be perceived by patients and the emergency care department as relatively less urgent conditions.^[4] However, delays in rendering appropriate emergency dental care to TDIs have been found to imperil their treatment outcomes significantly, creating various unfavorable complications.^[3],[5],[6] Furthermore, normal growth and development of the alveolar bone affect future treatment choices and outcomes, causing functional, aesthetic, and psychological problems.^[3],[6],[7] Several studies have shown that most people affected by TDI worldwide are not given appropriate and timely emergency dental treatment.^[3],[8] All such associated consequences with increased TDIs cases potentially raise the financial burden on patients, parents for receiving the optimal treatment, and on health-care providers for delivering the appropriate treatment on correct time.^[3],[9]

Dental trauma can lead to injuries involving a tooth and its supporting tissues. Crown fractures and luxation are the most commonly occurring TDI.^[10] Luxation injuries constitute a severe TDI that accounts for 18‒33% of TDI in permanent teeth.^[11] The magnitude of damage to the tooth and its supporting structures due to dental trauma is governed by the direction and energy (force) of the impact (blow) and the resilience of the affected oral structures.^[12] Luxation injury can damage periodontal structures or tissues, whose severity depends on the type of injury.^[13] Proper diagnosis, treatment planning, and follow-up are important for improving favorable outcomes.^[10]

Although different types of treatment modalities for luxation injuries have been reported in dental literature, but the International Association of Dental Traumatology (IADT) guidelines aid in providing the updated evidence-based approaches for appropriate treatment of each type of dental traumatic injury.^[14] Although digital or manual repositioning methods can manage luxation injuries on permanent teeth, surgical repositioning and stabilization with a splint can be done by orthodontic repositioning utilizing the light force traction of super-elastic NiTi archwires.^{[11],[12],[14],[15],[16]} There is a lack of published case reports about the fixed orthodontic modality approach for repositioning, alignment, levelling, detailing, and finishing to restore the functions and aesthetics of laterally luxated teeth caused by traumatic occlusion among adolescent patients whose dental treatment was delayed. The current article presents a case report about an orthodontic treatment modality that used light-force traction for laterally luxated permanent incisors and traumatic crossbite relations (traumatic occlusion) in a 13-year-old adolescent female patient with a history of dental trauma two weeks earlier. This case report has thoroughly described the clinical steps for managing the present case. The manuscript of this article has been prepared according to CARE case report guidelines.

Case Report

A 13-year-old female approached the outpatient department of Pediatric and Preventive Dentistry, Dr. Z.A. Dental College Hospital, Aligarh Muslim University (AMU), Aligarh, India and reported difficulty in chewing food due to irregular upper front teeth. The patient revealed a history of trauma to her upper anterior teeth due to a fall over a water hand pump 15 days ago at home. The local clinical practitioner provided initial treatment for pain and bleeding of oral tissues, but no appropriate dental treatment was provided for the affected teeth. The patient’s medical history was insignificant as she had no general health problems in the past; and her immunizations had been completed as per national guidelines. The patient’s family and psychosocial history were irrelevant. Her personal history revealed good oral hygiene practices, including daily brushing her teeth and the absence of deleterious oral habits.

The patient was in a systemically healthy condition based on a general physical examination. As per Frankl’s behavior rating scale, the patient displayed cooperative and positive clinical behavior. Extraoral examination revealed a healing scar mark on the vermilion region of her upper lip. A bilateral symmetrical face, mesocephalic head shape, mesoprosopic facial form, orthognathic profile, and competent lips were also present [Figure 1]a. Intraoral examination revealed lateral luxation of 21 and 22 in the palatal direction, respectively [Figure 1]b. Traumatic occlusion due to the locked position (crossbite) of luxated teeth 21 and 22 with lower anterior teeth was observed [Figure 1]c, d]. Bilateral Angle’s class-I molar relation was present. The interdental papillae of teeth 21 and 22 were inflamed, and there was mild pain in these teeth during palpation.

Figure 1: Pre-treatment clinical images showing: (a) frontal facial view; (b, c, d) intraoral view depicting palatally luxated incisors 21 and 22 in crossbite relation (traumatic occlusion); (e, f) orthopantomograph (OPG) and Intra-oral peri-apical (IOPA) radiograph demonstrating slightly increased PDL space around the apical region of the luxated teeth

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Radiographical evaluation (intraoral periapical radiograph and orthopantomogram) showed the widening of periodontal ligament (PDL) space at the root apex of tooth 21, thereby confirming its extrusion [[Figure 1]e, f]. Periapical radiolucency with tooth 11 was evident. No associated fracture of the luxated teeth or jaw was observed in the radiographs [[Figure 1]e, f].

Based on the patient’s trauma history, clinical examination, and radiographical evaluation findings, the clinical diagnosis of Ellis Class-VII. (i.e., lateral luxation of teeth 21 and 22 in the palatal direction with traumatic occlusion interference due to the locked position /crossbite relation of luxated teeth) was established. Accordingly, an appropriate treatment plan was determined. The treatment plan comprised immediate palliative treatment for relieving the traumatic occlusion (luxated teeth in the locked position), definitive treatment for repositioning, aligning, and levelling the luxated teeth by single-arch fixed orthodontic therapy using NiTi archwire, along with periodic endodontic and clinical follow-up evaluations.

The patient and her parents were informed about the clinical condition, and all treatment options were explained to them. Hence, informed consent and assent were obtained from the parents and the patient to commence treatment.

The functional posterior bite plane was fabricated at the first visit with cold-cure acrylic resin material [[Figure 2]a. It was temporarily cemented onto the lower arch to relieve and open or disocclude the traumatic bite (crossbite relation) of luxated teeth [Figure 2]b. Subsequently, the patient was recalled after two days. Bondable molar (buccal) tubes bilaterally bonded on the maxillary first molars. Metallic orthodontic brackets of the pre-adjusted edgewise appliance of MBT (McLaughlin, Bennett and Trevisi) system with bracket prescription of 022” × 028” slot were bonded to the luxated teeth (21 and 22) and other maxillary teeth [Figure 2]c. The 0.012” super-elastic NiTi (Nickel-Titanium) archwire was placed into the brackets slot and secured by elastic ligature ties [Figure 2]c. The patient was advised to maintain oral hygiene meticulously.

Figure 2: Clinical images showing: (a) functional posterior bite plane on articulator; (b) functional bite plane cemented onto the lower dental arch; (c) metallic orthodontic brackets of pre-adjusted edgewise appliance of prescription MBT (0.022” × 0.028” slot) bonded onto the upper arch with super-elastic NiTi of 0.012” diameter archwire and secured by elastic ligature ties

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The patient’s condition was reviewed after three weeks. Significant alignment of luxated teeth 21 and 22 into the arch was observed [Figure 3]a, b]. Furthermore, the traumatic occlusion of the luxated teeth was found to have resolved remarkably [[Figure 3]a, b]. The posterior bite plate was removed. However, the cervico-incisal levelling of teeth 11 and 22 were slightly disturbed [[Figure 3]a, b]. Hence, the archwire was engaged in the lower wings of the brackets of teeth 11 and 21 to correct the levelling of the same [[Figure 4]a. The archwire in these wings was secured using a stainless-steel ligature wire (0.010”) tie [Figure 4]a. After three weeks of fixed orthodontic therapy, a significant improvement in the alignment and levelling of the luxated teeth was observed [Figure 4]b. Then, an SS archwire with a diameter of 0.014” was inserted into the brackets for retaining and stabilizing the treated teeth in the appropriate positions of the dental arch. [Figure 4]b, c]. The same fixed orthodontic appliance was continued for the next month for retention [[Figure 4]c, d]. The patient demonstrated good compliance with the treatment progress and outcomes.

Figure 3: Clinical intraoral images after three weeks showing the frontal and occlusal views; (a, b) significant repositioning and effective alignment of teeth 21 and 22 by traction using NiTi arch-wire

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Figure 4: Clinical intraoral images demonstrating the treatment progress: (a) the NiTi archwire was inserted into the lower wings of the brackets of 21 and 22 for leveling their incisal edges; (b) after three weeks, leveling was achieved; (c, d) the detailing and finishing of the involved teeth was accomplished; the treated teeth were stabilized during the retention phase by using SS archwire with a diameter of 0.014”

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Subsequently, the debonding of the brackets was done [[Figure 5]a, and ultrasonic scaling [Figure 5]b and polishing followed by fluoride gel application were performed [Figure 4]b, c]. The patient was found comfortable throughout the treatment and satisfied with the favorable treatment outcomes of the functions and aesthetics of the involved teeth [[Figure 5]e]. A removable, vacuum-formed clear retainer for the upper arch was delivered to the patient [Figure 5]d. The clinical, endodontic, and radiographic evaluations from the follow-up visits were normal. The patient did not have pulpal necrosis, external or internal root resorption, or ankylosis. The patient was advised for long-term follow-up dental visits.

Figure 5: Follow-up clinical images after one month of retention phase showing: (a, b, c) intraoral views after debonding and finishing the upper arch, lower, and frontal view of the upper arch; (d) a thermoplastic retainer for the upper arch; (e) restoration of facial aesthetics and smile after the completion of the treatment

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Discussion

The International Association of Dental Traumatology (IADT) has described lateral luxation as a “displacement of the tooth in any lateral direction usually associated with a fracture or compression of the alveolar socket wall or facial cortical bone.”^[14] It has been suggested in the literature that if appropriate treatment of the extruded or laterally luxated permanent teeth is not done immediately or is delayed by more than three to four days, the traumatized teeth will be difficult to reposition into their original position by manual or digital repositioning maneuver. Studies suggest that reduction (reposition) procedures should be postponed or deferred to allow the teeth to realign themselves or that repositioning should be done by an orthodontic traction approach.^[15] As this report shows, the case was successfully and effectively managed through an orthodontic approach.

An orthodontic intervention may be imperative in the acute phase of trauma management of lateral luxation injuries whenever displaced (luxated) teeth cause occlusion interference. In this case, bite opening (i.e., relieving the traumatic occlusion) is done by employing bite-raising techniques like placing GIC stops on the occlusal surfaces of molars or giving posterior bite planes.^[16] In the present case, the patient, who had palatally luxated teeth in crossbite relation (traumatic occlusion), was relieved by providing a functional posterior bite plane. A functional bite plane was given to the patient to help her chew the soft food. The orthodontic movement of luxated teeth through short-term minimal light forces aims to remove the occlusal interference (premature contacts) instead of precisely repositioning the tooth.^[16] In the present case, since the patient only availed treatment for her TDI two weeks after the dental trauma, a fixed orthodontic treatment with light orthodontic forces of NiTi archwires was employed for the traction of her palatally luxated teeth (21 and 22) to correct their locked position (traumatic occlusion).

In the dental literature, very few cases of luxated teeth managed with orthodontic repositioning have been reported.^[11],[17] One study reported that laterally luxated teeth could be orthodontically moved after a traumatic injury event by immediate intervention using a fixed orthodontic appliance with nickel-titanium arch-wire, which exerts light forces, resulting in repositioning in around three to five days or longer.^[11],[17]

Various relevant factors dictate the treatment modalities for a luxation injury. One important factor for the treatment prognosis is the time elapsed between the dental trauma event and establishing a proper diagnosis of the condition.^[18] Delayed repositioning with manual or digital maneuvers is difficult if a clot is formed in the socket.^[18] Similarly, in the present case, since the patient only availed dental treatment two weeks after her injury, the displaced teeth had locked, and clots had formed in the socket, making manual repositioning impossible.

Orthodontic intervention using light orthodontic force for the traction of injured teeth was proven to be comfortable, non-invasive, and without any complications. The patient at each follow-up visit was asymptomatic without any clinical signs and symptoms of pulpal necrosis, root resorption, or periradicular pathology. Considering the ALADAIP (as low as diagnostically achievable, being indication-oriented and patient-specific) and ALARA (as low as reasonably achievable) principles of radiography in pediatric patients, unnecessary, injudicious, and frequent X-ray radiation exposures for dental radiographs were avoided in the follow-up visits.^[19],[20] Hence, clinical oral examination findings and the patient’s follow-up history were found satisfactory and sufficient for substantiating the absence of any complications. There was an absence of crown discoloration, abnormal mobility, tenderness, pain, swelling, abscess, or sinus tract, which indicated the absence of pulpal necrosis and periapical pathology. No metallic sound was detected on the percussion test, which confirmed the absence of ankylosis. Hence, radiographs were not required in the follow-ups.

Furthermore, a pediatric dentist should be prudent and have the expertise and an evidence-based approach to successfully treating dental trauma cases in pediatric patients treating. Even AAPD and EAPD suggest the sensible use of dental radiographs with clinical judgment and recommend pediatric patients’ lesser exposure to X-ray radiation.^[19],[20] Radiographs should be used only when the clinical evaluation findings are not evident or confirmatory during follow-up visits.^[19],[20] In the follow-up clinical evaluation of the present case, after 1.5 years of completion of treatment, the Covid-19 pandemic began worldwide. The teledentistry approach was adopted for follow-ups of the non-essential category of dental conditions. In the present clinical case, follow-up was conducted using the online teledentistry approach because of the Covid-19 pandemic.

The benefits of orthodontic repositioning in dental trauma cases are due to three key factors: extremely light and controlled forces are applied, tissue reorganization is permitted owing to the application of light orthodontic forces, and local anesthesia is unnecessary.^[21] The last factor (i.e., no need for local anesthesia injection) is of considerable clinical significance, especially when dealing with pediatric age group patients with dental injury and fear or anxiety.

The literature reveals that when repositioning is not done appropriately or the time elapsed is exceedingly larger, common adverse sequelae, such as pulpal necrosis, infection-related root resorption, ankylosis, or marginal bone loss of alveolus, may occur.^[22] However, no sequela of resorption occurs with a correctly performed repositioning technique, and appropriate treatment is rendered within a relatively shorter period following the TDI.^[18] Patient motivation, education, and compliance were found to be important in managing the present clinical case, which was mainly possible with fixed orthodontic therapy.

Conclusion

Based on the present case report, it can be concluded that lateral luxation injuries concurrently with traumatic occlusion (locked position of luxated teeth) can be effectively repositioned by orthodontic traction using light orthodontic forces of super-elastic NiTi archwire, especially in patients who delayed reporting to a dental clinic. The follow-up clinical evaluations showed excellent treatment outcomes. The repositioning of the involved teeth was fast and non-invasive, and there was no need for antibiotics or local anesthesia injections. In addition, there was no pulpal necrosis, root resorption, or ankylosis, as assessed by clinical evaluation. Most importantly, the patient showed acceptance, compliance, and satisfaction with the orthodontic repositioning treatment modality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Authors’ contributions

Khan MK was involved in clinical examination, diagnosis, preparing a treatment plan and management and follow-up evaluation of the patient. He prepared the manuscript of this case-report article.

MK Jindal was involved in clinical examination, diagnosis, preparing a treatment plan and management of the patient.

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