Orthodontic treatment in patients with reimplanted ... - Dental Press

O n l i n e A r t i c l e *Orthodontic treatment in patients withreimplanted teeth after traumatic avulsion:A case reportSimone Requião Thá Rocha**, Alexandre Moro***, Ricardo César Moresca****, Gilson Sydney*****,Fabian Fraiz******, Flares Baratto Filho*******AbstractIntroduction: The high prevalence of individuals with dental trauma prior to orthodontictreatment justifies the precautions that should be followed before and during treatment,taking into account all possible effects of orthodontic movement on traumatized teeth.Among the major traumatic dental injuries, avulsion with subsequent tooth reimplantationentails a higher risk of complications, such as pulp necrosis, root resorption and ankylosis.Therefore, it gives orthodontists several reasons for concern. Objective: This casereport aims to analyze the implications of tooth reimplantation after traumatic avulsionin patients requiring orthodontic treatment. Conclusions: Tooth movement of a reimplantedtooth after traumatic avulsion is viable, provided that no signs of abnormality arepresent. Ankylosed teeth, however, are not eligible for orthodontic movement but shouldbe preserved as space maintainers until root resorption is completed, provided that theteeth do not present with severe infraposition. Should an ankylosed tooth be severelyinfraposed, crown amputation and root burial are indicated as a means to preserve thealveolar bone in the region, since resorption will occur by replacement of the buried root,as was the case in this report.Keywords: Tooth movement. Dental ankylosis. Tooth trauma.Editor’s summaryOrthodontic movement after tooth reimplantationis not impossible. According toMalmgren et al, 1 however, after avulsion ofpermanent teeth followed by reimplantation,a follow-up period of at least one year is necessary,since most root resorption occurs duringthe first year post-trauma. Boyd, Kinironsand Gregg 2 found that a time span ranging between102 and 997 days 3 elapsed before root* Access www.dentalpress.com.br/journal to read the full article.** MSc student in Clinical Dentistry, Positivo University. Professor of the Specialization Course in Orthodontics, Positivo University.*** PhD in Orthodontics, FOB-USP. Associate Professor, UFPR, graduate and postgraduate studies in Orthodontics. Head Professor in the MSc Program ofClinical Dentistry, Positivo University.**** PhD in Orthodontics, FO-USP. Associate Professor, UFPR, graduate and postgraduate studies in Orthodontics. Head Professor in the MSc Program ofClinical Dentistry, Positivo University.***** PhD in Endodontics, FO-USP. Head Professor of Endodontics, UFPR.****** PhD in Pediatric Dentistry, FO-USP. Associate Professor of Pediatric Dentistry, UFPR.******* PhD in Endodontics, Pernambuco Federal University. Coordinator of the MSc Course in Clinical Dentistry, Positivo University.Dental Press J Orthod 40 2010 July-Aug;15(4):40-2

Rocha SRT, Moro A, Moresca RC, Sydney G, Fraiz F, Baratto F Filhoresorption was detected, suggesting the needfor a longer follow-up period before startingorthodontic treatment.When the periodontal ligament experiencesextensive damage a small amount of survivingcells near the root surface triggers a repairprocess through rapid osteogenesis, leading toankylosis of the tooth 4 and its subsequent lossand replacement. Alveolodental ankylosis involvesfusion of the alveolar bone with the rootsubstance and consequent disappearance of theperiodontal space, which loses its structure andfunction. The close contact between dental tissuesand alveolar bone structure furthers thebone remodeling process. This results in resorptionof bone tissue and part of the tooth tissue,which will be partially or totally replacedby new bone formation. Resorption by replacementincreases if the avulsed tooth is allowedto remain outside the oral cavity for extendedperiods of time. It ranges from only 9.5% resorptionin short periods (fewer than fifteenminutes) to 100% resorption if periods exceedsixty minutes, in a dry medium. 5Extraction is recommended in cases of inclinedadjacent teeth or extensive infraposition.1 In other cases, teeth should be examinedat intervals of six months until root resorptionceases and the tooth crown either comes looseor can be removed with forceps, after most ofthe root has been replaced by bone. 6 Clinicalexperience has shown that extraction of ankylosedteeth involves substantial bone loss bothhorizontally and vertically, which affects, in particular,the thin buccal bone wall in the maxilla.6 To prevent this loss, Malmgren 1,6 describeda technique that involves removal of the toothcrown with subsequent closure of the alveoluswith the root inside it. When resorption by rootreplacement takes place it preserves or even enhancesalveolar bone height in the vertical direction.It also preserves the alveolar bone inthe buccolingual direction, which improves theconditions for orthodontic treatment—if necessary—and/orsubsequent placement of a prosthesisand/or implant.Ankylosed teeth should therefore be preservedas space maintainers until root resorptionis completed, provided that the teeth donot present with severe infraposition. Should anankylosed tooth be severely infraposed, crownamputation and root burial are indicated as ameans to preserve the alveolar bone in the region,since resorption will occur by replacementof the buried root, as was the case in this report.Questions to the authors1) What precautions should professionalsfollow when planning orthodontic treatmentfor patients with a history of trauma?Orthodontists should first perform a carefulanamnesis looking for information about the historyof trauma. Injuries to the teeth involve multipleconsequences ranging from a small crack inthe enamel to tooth loss. Some lighter injuriesrarely pose a risk to the health or survival of atraumatized tooth, while others are more severe,such as intrusions and avulsions followed by reimplantation,and pose a greater risk of complications,including pulp necrosis, root resorption tothe extent of marginal bone loss and subsequenttooth loss. The prognosis for several types oftrauma seems to depend on the type and severityof the injury (measured by the extent of damageto the periodontal ligament). A detailed clinicalradiographic(periapical) assessment can providea thorough diagnosis of pulp changes, crownfractures, root fractures, possible root resorptionprior to orthodontic treatment, and ankylosis.Dental Press J Orthod 41 2010 July-Aug;15(4):40-2

Orthodontic treatment in patients with reimplanted teeth after traumatic avulsion: A case reportIn some cases, a scan of the traumatized toothmay reveal images that go unnoticed in radiographs.Should the injured tooth show no clinicalor radiographic changes, a post-trauma periodshould be observed—three months in cases ofminor injuries such as coronal or coronoradicularfractures without pulp involvement, concussionand subluxation, and 1 to 2 years in cases of rootfractures, intrusion, reimplantation after avulsionand lateral luxation with moderate or severedisplacement—, and then orthodontic treatmentcan be performed normally. Orthodontists willnot be able to move ankylosed teeth because theyare not amenable to orthodontic movement. Radiographicfollow-up throughout the orthodontictreatment is also essential.2) Is tooth reimplantation a contraindicationto orthodontic treatment?Tooth avulsion with subsequent reimplantationis the traumatic injury that involves thegreatest risk of complications due to a high likelihoodof bacterial infection through both thepulp and the periodontium. However, the orthodonticmovement of reimplanted teeth is possible,provided that normal conditions are restoredand maintained for period of at least one yearwith clinical-radiographic follow-up. Accordingto Malmgren et al, 1 most root resorption afterreimplantation occurs during the first year posttrauma.Boyd, Kinirons and Gregg 2 found that atime span ranging between 102 and 997 days 3elapsed before root resorption was detected, suggestingthe need for a longer follow-up periodbefore starting orthodontic treatment.3) Is there general agreement in the literatureregarding orthodontic treatment in patientswith traumatized teeth or are therestill different approaches to this issue?The literature is indeed very consistent in thisregard. Dental trauma does not contraindicateorthodontic treatment, provided there are nopulp or periodontal changes and/or root resorption.However, some studies indicate that traumatizedteeth are more predisposed to resorption.But these findings are not conclusive because thefinal outcome of traumatized tooth treatmentcan take more than five years to surface. This isone of the factors hampering the analysis of theeffects of orthodontic movement on traumatizedteeth. These studies involve a small number ofpatients, who present with different types ofinjuries and are treated by different researchersusing a variety of orthodontic appliances. Thesefactors combine to render inconclusive any findingsregarding the effects of orthodontic treatmenton traumatized teeth.ReferEncEs1. Malmgren O, Malmgren B, Goldson l. Abordagem ortodônticada dentição traumatizada. In: Andreasen JO, Andreasen FM.Texto e atlas colorido de traumatismo dental. 3ª ed. PortoAlegre: Artmed; 2001.2. Boyd DH, Kinirons MJ, Gregg TA. A prospective study of factorsaffecting survival of replanted permanent incisors in children. IntJ Paediatr Dent. 2000 Sep;10(3):200-5.3. Kinirons MJ, Boyd DH, Gregg TA. Inflammatory andreplacement resorption in reimplanted permanent incisor teeth:a study of the characteristics of 84 teeth. Endod Dent Traumatol.1999 Dec;15(6):269-72.4. Andreasen JO. Relationship between cell damage in theperiodontal ligament after replantation and subsequentdevelopment of root resorption. Acta Odontol Scand.1980;39:15-25.5. Chappuis V, von Arx T. Replantation of 45 avulsed permanentteeth: a 1-year follow-up study. Dent Traumatol. 2005Oct;21(5):289-96.6. Malmgren B, Cvek M, Lundberg M, Frykholm A. Surgicaltreatment of ankylosed and infrapositioned reimplanted incisorsin adolescents. Scand J Dent Res. 1984 Oct;92(5):391-9.Contact addressSimone Requião Thá RochaAv. Visconde de Guarapuava, 4663, ap. 2301 – BatelCEP: 80.240-010 – Curitiba / PR, BrazilE-mail: simone_tha@hotmail.comDental Press J Orthod 42 2010 July-Aug;15(4):40-2