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A MULTIDISCIPLINARY TREATMENT OF A
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 “main” — 2010/9/14 — 14:47 — page 17 — #1

Brazilian Journal of Dental Traumatology (2010) 2(1): 17-21

© 2010 Sociedade Brasileira de Traumatologia Dentária
ISSN 2175-6155
http://www.sbtd.org.br/journal

A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA

Rosana Belchior Miranda1 , Marı́lia Fagury Videira Marceliano-Alves2 , Marcelo Rolla de Souza3 ,
Sandra Rivera Fidel4 and Rivail Antonio Sérgio Fidel5

Received on June 10, 2010 / Accepted on August 11, 2010

ABSTRACT

Unfortunately, dental trauma is a common event among teenagers practicing sports. The injuries may range from involving only the teeth to being
associated with a complex oral traumatism. The prognosis depends on a good diagnosis and an appropriate treatment plan. This study presents
a clinical case of a 15-year-old male, who had an accident during a soccer match. The trauma affected three teeth, their periodontal supports
and oral tissues. A severe intrusion committed the #21 tooth and both #11 and #12 teeth suffered subluxation. The teeth suffered crown fracture,
without pulp exposure. Upon urgency visit the professional carried out the splint with orthodontic wire to fix the #11 and #12 teeth, besides the
suture of gingival tissue laceration. The patient was designated to Orthodontics for extrusion of the #21 tooth, which was essential to endodontic
and restorative treatment. Pulp sensitivity of #11 and #12 teeth was tested for 7 months after trauma resulting in negative response. This condition
led to endodontic indication to both of them. Sixteen months after the trauma, periapical radiograph showed a radiolucent image limited around
the root apex of the #21 tooth that was, then, submitted to periradicular surgery. At 4 years follow-up, the area seemed healthy and the periapical
radiograph revealed evidence of bone repair.

Keywords: Dental trauma, intrusion, oral surgery.

Correspondence to: Rosana Belchior Miranda

R. Sorocaba, 115/901, Bl. 2, Botafogo, 22271-110 Rio de Janeiro, RJ, Brasil – E-mail: rosanabelchior@uol.com.br
1 DDS, MSc, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil.
2 DDS, MS, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil.
3 DDS, MS, Endodontics Department, Santos-Dumont Dental Clinic of Brazilian Air Force, Rio de Janeiro, RJ, Brazil.
4 DDs, MSc, PhD, Department of Integrated Clinical Procedures (Proclin), State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
5 DDs, MSc, PhD, Endodontics Department, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
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18 A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA

INTRODUCTION condition because of a collision during a soccer match. The situa-

Oro-facial injuries are commonly result from assaults, accidents with tion involved his maxillaries left (#21) and right (#11) central incisors
various means of transport, falls or during sports-related activities and the maxillary right lateral incisor (#12). After carefully cleaning
[2, 9, 23]. They constitute frequent urgency situations at dental offi- and sewing of gingival laceration at that area (black braided silk 4.0 –
ces. Ethiconr – Johnson & Johnson, São Paulo, Brazil), it was possible to
Dental traumatic injury may include from enamel fracture to total evaluate the extension of the traumatism.
tooth loss. Predominantly, this type of trauma is seen especially in The clinical examination showed that all the involved teeth had
growing male school-age individuals [4, 6, 19, 21]. The injuries that their crowns fractured without pulp exposure. Moreover, the #11 and
involve front teeth may result in unfavorable functional and aestheti- #12 teeth showed mobility and did not demonstrate sensitivity to a
cal effects, cause painful sintomatology and directly affect self-esteem cold test with refrigerant gas (Endo-Frostr – Roeko/Langenau – Ger-
[4, 6, 14]. many) such as the #21 tooth.
Enamel and dentin fractures without pulpar exposure have favora- The periodontal injury consisted of subluxation of #11 and #12
ble prognosis, even in cases of late treatment; however, dental care is teeth and a severe intrusion of the #21 tooth, revealed by radiographic
required for evaluation, treatment and proservation of the case. Coro- examination (Figure 1).
nary fracture with pulp exposure, concussion, subluxation and intrusive
luxation are regarded as mild-severity injuries, but they require imme-
diate care [2, 5, 6, 9]. Avulsion, root fracture and alveolar fracture are
regarded as more serious conditions, and must also receive prompt
care [3, 9, 16].
Intrusive luxation means the axial displacement of the tooth inside
the socket [1, 3, 7]. Traumatic intrusion represents 0.3 to 2% of the
traumas affecting the permanent teeth [9, 11]. Due to the nature of this
injury, with damage to gum tissue, periodontal ligament, alveolar bone
wall and pulp, this is the scenario for a series of complications, inclu-
ding loss of gingival attachment, marginal bone loss, root resorption,
ankylosis, pulp necrosis and paralysis of root formation in immature  Figure 1 – Panoramic radiographic examination.
teeth [6].
Orthodontic wire has been used as a semi-rigid contention to set-
At the moment of the impact, the periodontal ligament is compres-
tle the teeth (Figure 2). Two days later the splint was removed from
sed against the alveolar bone wall, fiber cutting occurs, as well as bone
the #21 tooth to allow some axial spontaneous movement.
wall fracture and section of the neurovascular bundle, which results in
pulp necrosis. In addition to the mechanical trauma, an intruded tooth
may be contaminated by oral bacteria, with consequent risk of infec-
tion. Andreasen & Andreasen [6, 8] consider that the cure for trauma
by intrusion is complex, resulting in complications in the cicatrization
process. The authors also report that intruded teeth with incomplete
root development usually re-erupt spontaneously, which could also oc-
cur to those with complete root formation, but it could take months,
thus allowing a root resorption process. Therefore, orthodontic extru- a) b)
sion was indicated, enabling the endodontic treatment after coronary  Figure 2 – a) semi-rigid contention; b) periapical radiograph.
exposure [13].
The suture was removed three days later of the first visit and the
This work aimed at reporting a clinical case of dental trauma with
light-curing resin restorations were immediately performed to make
multidisciplinary treatment, performed at the Santos-Dumont Dental
aesthetics better and to protect the dentin-pulp complex.
Clinic of Brazilian Air Force.
Semi-rigid contention was established for three weeks. At that
moment, the patient began an orthodontic treatment to get the #21
CASE REPORT tooth extrusion in order to bring it back to its original position (Fi-
A 15-year-old Caucasian male came to the Santos-Dumont Dental Cli- gure 3). Six months later, the orthodontic appliance was removed and
nic of Brazilian Air Force (Rio de Janeiro, RJ, Brazil) in an urgency the #21 tooth endodontic treatment was carried out.

Brazilian Journal of Dental Traumatology, Vol. 2(1), 2010

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ROSANA B. MIRANDA, MARÍLIA F. V. MARCELIANO-ALVES, MARCELO R. DE SOUZA, SANDRA R. FIDEL and RIVAIL A. S. FIDEL 19

The perirradicular surgery was planned for this area and consisted
of apical lesion curettage, apicectomy and retrograde filling with mine-
ral trioxide aggregate (ProRoot 2 MTAr – Dentsply, USA) (Figure 6).

a) b)
 Figure 3 – a) #21 tooth orthodontic extrusion; b) periapical radiograph.

After a month, patient has come back to review the #11 and #12
teeth pulp condition that once again revealed negative response to sen-
sitivity cold test, besides the periapical radiograph showed external root
a) b)
apical resorption of #21 tooth (Figure 4). Thus the #11 and #12 teeth
were undergone to endodontic treatment and the #21 tooth to endodon-  Figure 6 – a) periapical lesion removed by curettage; b) surgical bone site showing
the #21 tooth apicectomy.
tic retreatment.
Six months after surgery, the patient was in excellent condition
with neither symptom nor signal of any problem. Periapical radiograph
suggested bone formation (Figure 7). Despite of the extensive surgi-
cal area, it was interesting to notice that there was not #22 tooth in-
volvement such as revealed by a positive response to sensitivity pulp
test. The histopathological test confirmed the diagnosis hypothesis of
a periapical cystic lesion.

 Figure 4 – #21 tooth endodontic treatment at a month follow-up.

a) b)
Six months after the endodontic retreatment, the clinical examina-  Figure 7 – 6 months follow-up: a) clinical aspect; b) periapical radiograph.
tion showed that there was an increase of volume, without symptom,
Patient returned after four years when the clinical and radiographic
at #21 tooth apical area corresponding to a well defined radiolucent
examinations found the teeth involved in this case of dental trauma and
image revealed by the periapical radiograph (Figure 5).
their periodontal tissues healthy (Figure 8).

 Figure 5 – Periapical radiograph 6 months after the #21 tooth endodontic retreat-
 Figure 8 – Periapical radiograph at 4 years follow-up.
ment showing a radiolucent image around its root apex.

Brazilian Journal of Dental Traumatology, Vol. 2(1), 2010

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20 A MULTIDISCIPLINARY TREATMENT OF A DENTAL TRAUMA
DISCUSSION
The consequences of dental trauma in permanent teeth may be as
follows: change of color, mobility, pulp necrosis, bone and dental
resorptions – which can occur by lack of immediate treatment or in-
dividual prognosis of the case [1, 3, 22, 12].
According to Andreasen, Bakland, Matras and Andreasen [9], the
frequency of injuries by intrusive luxation is low (1.9%), but the treat-
ment is complex. Dentinal protection was recommended in case of
intrusion-related crown fracture, which was first performed in the case
reported, as the exposed dentin may allow bacterial invasion. Besides,
the aesthetical recovery allowed that the patient returned to his nor-
mal activities.
The most common complication of intrusive luxation is pulp ne-
crosis, due to ischemic changes, probably because of compression of
the neurovascular bundle [1, 3, 10, 20]. As soon as the dental repos-
itioning was achieved, the endodontic treatment was executed; how-
ever, there was still apical resorption and further development of the
periradicular lesion.
According to Andreasen & Andreasen [8], the chosen treatment
for the repositioning must be the orthodontic extrusion, so that the
crown is exposed as soon as possible, thus enabling the endodontic
treatment, which is a means of preventing external root resorption that
occurs, according to the same authors, around 3 weeks after. In this
case, the crown was exposed only within six months of traction. Con-
sidering the severity of the intrusive luxation, there must have been
damage to the periodontal membrane and the root surface, according
to studies by several authors [1, 3, 10, 17].
The authors suggest a 5-year follow up period, due to the risk of
further complications during the cicatrization process, such as resorp-
tion of the root surface [1, 3, 10, 17, 20].
Fidel et al. [15] affirmed that intrusion treatment is a challenge,
and that the focus must be on the most serious damage and the cure
prognosis. Therefore, in the case presented, the surgery was planned
in order to perform curettage of the periradicular lesion, carry out an
apicectomy and, also, refill with a bone-formation biocompatible and
biostimulating material – MTA [3, 25, 26]. In recent literature review,
Torabinejad and Parirokh [27] reaffirmed that MTA was firstly recom-
mended as root-end filling material and, by analyzing a great deal of
studies, they emphasized the superior results for this material regard-
ing the chemical and physical properties as well as the antibacterial
activity, the excellent sealing ability and biocompatibility.
The literature shows that long-term follow up of traumatized pa-
tients is fundamental [7, 8, 18]. Such fact was evident in the case pres-
ented, as #21 tooth was certainly preserved due to regular follow up
of the patient for 18 months, which allowed the interventions to occur
at those very moments when the changes were observed. Although the
patient has not responded further calls and had returned after four years,
one can observe the satisfactory result of the case.
Souza-Filho et al. [24] reaffirmed that dental traumatic injuries in
the emergency service is high, and that it is extremely important to
divulge the preventive and educative approach on dental traumas,
especially in educational institutions, raising the professionals’ awa-
reness on the issue, since urgency attitudes at the accident site may
improve the quality of life [2].
CONCLUSION
The occurrence of dental trauma is frequent in children and teenagers.
The first aid to the patient, diagnosis and correct conduct in relation to
the trauma, as well as the long-term proservation are extremely impor-
tant for the prognosis and maintenance of the tooth in the oral cavity.
The long follow up of the patient and the interventions carried out at
proper moments determined the success of the case presented.
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