CLINICIAN'S CORNER

Orthodontic treatment after intrusive

dislocation and fracture of the maxillary
central incisors
Sergio Luiz Mota Ju
nior,a Daniela Gomes de Rezende Azevedo,b Marcio Jose
da Silva Campos,b
c b
Orlando Motohiro Tanaka, and Robert Willer Farinazzo Vitral
Rio de Janeiro, Rio de Janeiro, Juiz de Fora, Minas Gerais, and Curitiba, Paran

a, Brazil

The treatment for intrusive dislocation is a clinical challenge and must be started soon after the intrusion injury.
The affected tooth or teeth must be extruded by using light forces. This case report of traumatic intrusion of per-
manent central incisors aims to describe and discuss the process of repositioning the teeth in the dental arch.
After a domestic accident, a 10-year-2-month-old boy suffered 11-mm intrusion of the maxillary central incisors
along with enamel-dentin fracture and subluxation of the maxillary lateral incisors. Treatment started 2 days after
the incident with an orthodontic extrusion of the maxillary central incisors with a fixed edgewise standard appli-
ance. Orthodontic arches were used, and the force vectors were directed to the desired locations for the repo-
sitioning of the teeth. The treatment for extrusion and stabilization of the maxillary central incisors lasted
5 months and 22 days. Orthodontic traction with a fixed appliance is an effective procedure for the extrusion
of both permanent maxillary central incisors intruded after trauma. Correct diagnosis, a short period between
the trauma and the beginning of treatment, and appropriate mechanics were determining factors for a successful
treatment. (Am J Orthod Dentofacial Orthop 2021;160:757-63)

I
ntrusive luxation or intrusion results from dental
trauma with an axial dislocation of the tooth into
the alveolar bone. It is a severe traumatic dental
injury because of the damage it causes to the gingival
tissue, contusion of both the periodontal ligament and
alveolar bone, and damage to the Hertwig's epithelial
root sheath when it happens during root development.1
It is an injury more common in deciduous dentition. The
incidence in the permanent dentition is between 0.3%
and 1.9%. These injuries can cause complications such
as pulp necrosis, inflammatory root resorption, anky-
losis, replacement resorption, and loss of marginal
bone support.2,3
a
Department of Pediatric Dentistry and Orthodontics, Rio de Janeiro Federal Uni-
versity, Rio de Janeiro, Rio de Janeiro, Brazil.
b
Department of Orthodontics, Juiz de Fora Federal University, Juiz de Fora,
Minas Gerais, Brazil.
c
Postgraduate Program in Dentistry, Orthodontics, School of Life Sciences,
Pontifical Catholic University of Paran
a, Curitiba, Paran
a, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Marcio Jos
e da Silva Campos, R Giuseppe Verdi, 111,
Residencial S~ao Lucas II, S~ao Pedro, Juiz de Fora, Minas Gerais 36036-643,
Brazil; e-mail, drmarciocampos@hotmail.com.
Submitted, August 2020; revised and accepted, April 2021.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2021.04.019
Imaging examination (x-ray and tomography) allows
observation as to whether there is a reduction of space
for the periodontal ligament around the root, as the
tooth lacks mobility ensuing trauma, and percussion
can make a high, metallic (ankylotic) sound. Dental
pulp tests generally offer negative results. Pulp revascu-
larization is possible in immature and not partially devel-
oped teeth.4
Intrusion is a traumatic injury most often related to
the development of pulp necrosis in teeth with complete
root formation.2 Therefore, the procedures for perma-
nent and deciduous teeth differ significantly,4 as treat-
ment options include spontaneous re-eruption,
orthodontic extrusion, and surgical repositioning. The
choice for the appropriate treatment relates to the stages
of root formation. Spontaneous re-eruption is recom-
mended for teeth with incomplete root formation,3
whereas orthodontic extrusion and surgical reposition-
ing are principal options for teeth with complete root
formation.4 In addition, immediate orthodontic extru-
sion expedites bone healing.1
The pace of orthodontic extrusion must be in har-
mony with the healing process of the marginal bone,1
applying light and constant orthodontic forces (30 to
40 g of force).5 Pulp necrosis and inflammatory root
resorption are the most frequent endodontic

757
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unior et al

complications.6 Therefore, it is recommended that the

root canal be treated with a temporary filling of calcium
hydroxide to increase the longevity of the affected
dental element.3,4 Calcium hydroxide offers pulp necro-
sis favorable biologic healing properties.3,4,7
Complications are proportional to the amount of
time elapsed between injury and intervention; therefore,
dental treatment must ensue immediately after the
trauma.8,9 This period is crucial for therapeutics, as it
directly impacts the prognosis.9 Finally, the unesthetic
nature of severe incisor intrusion has psychological im-
plications dictating immediate intervention.10
This case report describes and discusses the treat-
ment of severe traumatic intrusion of both maxillary
central incisors.

CASE REPORT
A 10-year 2-month old boy in the mixed dentition
stage suffered a domestic accident with a head injury Fig 1. Image of the area of the maxillary incisors after
while playing on the floor of his home. In the accident, trauma. (A) Front view. (B) Occlusal view.
the patient's central incisors were intruded 11 mm,
with enamel-dentin fracture and subluxation of the
done to evaluate both the root and bone surfaces of
maxillary lateral incisors. The patient had good overall
the affected area (Fig 5).
health without systemic alterations.
As the mobility of the maxillary lateral incisors was
In the first clinical examination, the patient com-
reduced, after 3 months 22 days, they were included in
plained of pain in the affected region and presented
the stabilization archwire of the same gauge as the pre-
alveolar mucosal swelling resulting from the injury.
vious ones. A superimposed 0.012-in nickel-titanium
The fragments of the maxillary central incisors were
archwire was inserted and tied from the second left pre-
lost in the accident, and only the palatal surfaces of these
molar to the right one to continue the extrusion of the
teeth were occlusally visible (Fig 1). The apices of the
maxillary central incisors (Fig 6). The palatal buttons
maxillary central incisors were closed (Fig 2).
were removed at 4 months and 5 days, and the brackets
The treatment proposal was immediate orthodontic
on the maxillary central incisors were repositioned cervi-
traction with a fixed appliance bonded to the perma-
cally to facilitate their extrusion. A 0.016-in stainless-
nent maxillary teeth. The lateral incisors were not
steel archwire was used to complete the extrusion of
initially used as anchorage units as they were mobile af-
the maxillary central incisors, and the braces were main-
ter the injury. A passive arch was made with a
tained for another 4 weeks for teeth stabilization and
0.0215 3 0.028-in stainless-steel wire supported by
alveolar bone formation.
the maxillary permanent first molars and first premo-
After removing the braces, the maxillary central inci-
lars. The orthodontic traction started with elastic chains
sors were restored with composite resin. (Figs 7 and 8
(with 30-40 g of force) linking the retention wire bends
on the region of the central incisors to the buttons show the clinical and x-ray aspects at the end of this in-
bonded to the palatal surfaces of the maxillary central terceptive stage of treatment). The patient was referred
incisors (Fig 3). Weekly examinations were performed to an endodontist for treatment of the maxillary central
at the early stage of treatment to verify if the intruded incisors and maxillary left lateral incisor. The 5-year
teeth were ankylosed. follow-up images indicate anatomic stability of the
As the teeth were extruded, new 0.0215 3 0.028-in maxillary central incisors (Fig 9).
stainless-steel archwires were made according to the
need for force direction for the teeth to reach their DISCUSSION
normal positions (Fig 4). Because part of the labial sur- Despite a large number of studies on the possible
faces of the maxillary central incisors was exposed, orthodontic treatments for traumatic dental intrusions,
brackets were bonded to assist the extrusion, and a there is no consensus on the best approach for these
cone-beam computed tomography (CBCT) scan was situations.11

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Fig 2. Periapical radiographs of the area of the maxillary incisors after trauma. (A) Lateral right incisor;
(B) central incisors; (C) lateral left incisor.

Fig 3. Intrabuccal images on the initial stage of treatment with steel edgewise standard brackets
bonded to the permanent maxillary teeth and buttons on the palatal surfaces of the maxillary central
incisors. Passive 0.0215 3 0.028-in gauge stainless-steel wire on the posterior teeth and chain elastics
with light forces to extrude the maxillary central incisors. (A) Right lateral view; (B) front view; (C) left
lateral view; (D) occlusal view.

However, researchers agree that a prompt start for

the extrusion is important to increase the odds of a suc-
cessful treatment, especially in patients with closed root
apices.6,8,9 A brief amount of elapsed time between
injury and the start of treatment reduces not only the
chances of ankylosis4 and external root resorption9 but
also the amount of time during which the patient has
to endure the psychological implications of the unaes-
thetic nature of severe incisor intrusion.10
In this case report, the patient presented a periapical
radiograph taken by a clinical dentist responsible for the
first evaluation 2 days before the orthodontic appoint-
ment. An initial CBCT was not available but was taken
subsequently at a later point in treatment.
Chaushu et al12 noticed a 96.7% success rate of or-
Fig 4. (A) Second archwire. (B) Image after 19 days of thodontic extrusion in patients who had traumatic intru-
treatment. sion when the treatment started between 1 and 90 days

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760
Fig 5. CBCT Image postbracket bonding. (A) Coronal view; (B) sagittal view: right side; (C) sagittal
view: left side.
Fig 6. Intrabuccal image after 3 months and 22 days of
treatment. Extrusion of the central maxillary incisors with
a 0.012-in nickel-titanium archwire superimposed on the
0.0215 3 0.028-in gauge steel stabilization archwire.
after the injury, with most of the first orthodontic exam-
inations taking place up to the third day after the inci-
dent.13,14 To not delay the start of the treatment,
braces were bonded to start the traction of the maxillary
central incisors in the first session because spontaneous
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unior et al
eruption is not expected of permanent teeth with closed
apexes intruded more than 7 mm in traumatic injuries.15
The lateral incisors had a subluxation; therefore, they
were not initially used as anchorage units.
The first stage of treatment consisted of applying or-
thodontic traction to the maxillary central incisors, sup-
ported by buttons bonded on their palatine surfaces.
Despite being only partially accessible, these were the
only teeth available for this procedure, which avoided
the need for surgical intervention to bond the acces-
sories on the vestibular surfaces or tooth drilling to fixate
metallic ligatures for traction.
The periapical x-ray images taken at the start of
treatment showed that the roots of the central incisors
were parallel, indicating that there was no intrusion
with the distal movement of the apices, which is com-
mon in most patients with a traumatic intrusion.1 There-
fore, it was possible to start the traction procedure in a
safe manner because the buttons bonded to the teeth
would not grant three-dimensional control of the move-
ment, as is the case when using brackets.
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unior et al
Fig 7. Intrabuccal images at the end of the interceptive stage of treatment. (A) Maxillary occlusal view;
(B) mandibular occlusal view; (C) right lateral view; (D) front view; (E) left lateral view.
Fig 8. Radiographs at the end of the interceptive stage of
treatment. (A) Panoramic radiograph; (B) periapical radio-
graph of the central and right lateral incisors; (C) periapi-
cal radiograph of the central and left lateral incisors.
The CBCT scan, which was done after there was
enough exposure of the crown of the incisors to allow
bracket bonding, revealed that extrusion up until that
moment had preserved root parallelism of the incisors.
Although an association of a removable appliance
with springs or vertical elastics is a possible solution
American Journal of Orthodontics and Dentofacial Orthopedics
761
Fig 9. Periapical radiograph of the central incisors at the
end of endodontic treatment.
for extrusion,12,16-22 patients often do not comply
with the recommended amount of time of use, thus
delaying the treatment16,17 and compromising thera-
peutic success,12 whereas fixed appliances have the
advantage of not depending on patients’ collaboration.
This fact, along with the existence of a sufficient number
of permanent teeth available for use as anchorage
units, guided the decision of using a fixed appliance
for extrusion.
A fixed appliance with flexible wire is not appropriate
for the extrusion of teeth that suffered intrusive luxa-
tion, as it leads to inclination and intrusion movements
of the adjacent anchorage teeth. The adjacent teeth
must ideally be immobilized during the extrusion of
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Fig 10. Five-year follow-up images. (A and B) Image of
the periapical radiograph of the area of the maxillary right
and left incisors; (C) CBCT image: Maxillary right incisor
sagittal view; (D) CBCT image: maxillary left incisor
sagittal view.
injured teeth.12 This justifies the use of a thick passive
stainless-steel arch (0.0215 3 0.028-in) with brackets
and orthodontic tubes with 0.022 3 0.028-in slots
as anchorage units. Light elastic forces ranging from
30 to 40 g were applied through chain elastics to start
traction.
The duration of treatment depends on several as-
pects, such as the severity of the intrusion,12 the pa-
tient's sex and age, number of teeth affected,23 the
amount of elapsed time between injury and interven-
tion,4,13 occurrence of fractures,4 condition of peri-
odontal tissue, and development stage of the affected
tooth.12,23 Despite these variables, the average duration
of treatment ranges from 21 to 150 days.12 The patient
reported in this paper lasted for 5 months and 22 days,
with a 4-week stabilization period.
The x-ray requested at the end of treatment showed
signs of external root resorption in the mesial surfaces of
the maxillary central incisors (Fig 8). The resorption was
visible apically to the cementoenamel junction of the
maxillary right central incisor and on the mesial surface
of the root of the maxillary left central incisor. These
findings, along with the negative response to pulp vital-
ity testing, required endodontic treatment of the
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maxillary central and left lateral incisors after orthodon-
tic treatment. The maxillary central incisors were then
restored with composite resin. It should be stressed
that at the start of orthodontic treatment, the trauma-
tized teeth had a positive response to pulp vitality testing
and no signs of necrosis; thus, there was no referral to an
endodontist at that stage of treatment. A comparison
between the images of the periapical x-rays taken at
the end of endodontic treatment sent by the endodontist
(Fig 9) and the images taken 5 years posttreatment
(Fig 10) shows stabilization of the resorption process
in the area. The x-ray image suggests that the maxillary
left central incisor presented posttraumatic resorption
with natural repair, as indicated by the line of the peri-
odontal ligament. Although there was no sign or symp-
tom suggestive of any issues during posttreatment
follow-up, patients with a history of dental trauma
should continue with radiographic follow-up even in
the absence of clinical signs or symptoms because of po-
tential late external cervical resorption24,25
The main factors that contributed to a favorable
outcome of the interceptive treatment reported here
were the short amount of elapsed time between injury
and intervention (2 days), the correct diagnosis, and an
adequate orthodontic therapy with a fixed appliance
and light forces. Periodic radiographic control is required
posttreatment because of the possibility of external root
resorption.2,3,6
CONCLUSIONS
Orthodontic traction with a fixed appliance was
effective for the extrusion of 2 permanent maxillary cen-
tral incisors intruded after trauma. Correct diagnosis,
starting the treatment promptly after the accident, and
appropriate mechanics were determining factors that
led to a successful treatment.
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