Luxation InjuriesWorld Health Organization Classification

Great Threat to Pulp Vitality(Luxations)Traumatizes supporting structures of the periodontiumPotentially severs pulpal blood supply entering the apical foramenWHO recognizes five main types of luxation injuries

Luxation InjuriesConcussionSubluxationExtrusive luxationLateral luxationIntrusive luxation

ConcussionClinical findings: tender to touch, not displaced no increased mobility. Sensitivity test are most likely positiveRadiographic findings: No abnormalitiesTreatment: No treatment is need but it is essential to monitor pulpal condition for one year

Concussion: follow upFollow up: clinical and radiographic examination at, 4 weeks, 8 weeks, 1 year with clinical and radiographic examinationFavorable outcome: Asymptomatic, positive pulp tests, can have false negative up to 3 months, continued root development, intact lamina duraUnfavorable outcome: Symptomatic, negative pulp test, can have false neg for 3 months no continuing root development, signs of PAP, endo tx appropriate for stage of root development

SubluxationClinical findings: tender to touch or tap, increased mobility, not displaced. Bleeding from the gingival crevice. May have negative pulp test initially indicating transient pulpal damage.Monitor pulpal response until a definitive pulpal diagnosis can be madeRadiographic findings: Abnormalities are usually not foundTreatment: no treatment is needed. Monitor pulpal status for one year

Subluxation: follow upFollow up at 2 weeks, 4 weeks, 8 weeks 6 months and one year with clinical and radiographic examinationFavorable outcome: asymptomatic, positive pulp test. Can have false negative up to 3 months. Continued root development of immature teeth. Intact lamina dura.Unfavorable outcome: Symptomatic, negative pulp tests, external inflammatory resorption, arrested root development, PAP, endo tx appropriate for stage of root development.

Extrusive Luxations

Extrusive LuxationClinical Findings: Tooth appears elongated and is excessively mobile. Sensitivity test give negative resultsRadiographic findings: Increased periodontal ligament space apicallyTreatment: Reposition tooth by gently re-inserting it into the socket. Stabilize for 2 weeks with a flexible splint. In mature tooth pulp necrosis is expected. With immature teeth watch for signs and symptoms of pulpal necrosis. Endodontic therapy indicated.

Extrusive Luxation: follow upRemove splint in 2 weeks. Perform clinical and radiographic exam at 2 weeks, 4 weeks, 8 weeks, 6 months, then yearlyFavorable outcome: Asymptomatic, clinical and radiographic signs of healed periodontium, positive pulp tests (false neg up to 3 mos), marginal bone height maintained, continued root development Unfavorable outcome: Symptoms and radiographic signs of apical periodontitis, negative response to pulp tests, if breakdown of marginal bone is noted splint for an additional 4 weeks, signs of external inflammatory root resorption, endodontic therapy appropriate for root development.

Inflammatory Root Resorption

Lateral LuxationsClinical findings: displacement usually palatal/lingual direction. Often immobile and percussion gives metallic sound. Fracture of alveolar process is present. Negative pulp tests.Radiographic findings: widen PDL, best seen on occlusal exposureTreatment: Reposition digitally to disengage from its boney lock and gently reposition to original location. Stabilize 4 weeks with flexible splint. Monitor vitality. If necrotic endodontic therapy is indicated to prevent root resorption

Lateral Luxations

Lateral Luxations

Lateral Luxations

Lateral Luxations

Lateral Luxations

Lateral Luxation: follow upFollow up: 2 weeks splint removal, 2-4-6weeks, 6-12 months and yearly for 5 years clinical and radiographic exam.Favorable outcome: asymptomatic, clinical and radiographic signs of normal periodontium. Positive pulp tests. Potential false neg. for 3 months. No loss of marginal bone height. Continued root development in immature teeth.Unfavorable outcome: Symptomatic with radiographic PAP. Negative vitality. (False negative up to 3 months) If marginal bone is breaking down splint for additional 4 weeks. External inflammatory root resorption or replacement resorption. Endodontic therapy appropriate for root development stage.

Intrusive LuxationClinical findings: tooth displaced axially into the alveolar bone. Immobile with metallic sound to percussion (ankylotic). Negative to vitality tests.Radiographic findings: PDL absent. CEJ more apical then adjacent non-injured teeth.Treatment: contingent on root development. Teeth with incomplete root development vs teeth with complete root formation

Intrusive Luxations

Intrusive Luxation: treatmentIncomplete root formation: Allow eruption with no intervention. If no movement within three weeks initiate orthodontic repositioning. If tooth was intruded more than 7 mm immediately reposition surgically or orthodontically.Complete root formation: allow eruption if intruded less than 3 mm. If no movement in 3 weeks reposition surgically or orthodontically before ankylosis sets in. More extensive intrusions promptly reposition surgically.Pulpal necrosis likely initiate endodontic therapy with CAOH 2 weeks after surgery.Once repositioned surgically or orthodontically stabilize with flexible splint for 4-8 weeks

Intrusive Luxation: Follow up2 weeks splint removal. Clinical and radiographic exam. Then continue checking at 4 weeks 8 weeks 6 months and yearly for 5 years.Favorable outcome: tooth erupting or in place. Intact lamina dura. No sign of resorption. Continued root development.Unfavorable outcome: Tooth locked in place (ankylotic) Apical periodontitis. External inflammatory root resorption or replacement resorption. Endodontic therapy appropriate for stage of root development.

Intrusive Luxation Immature

Re-erupting

Replacement Resorption(Ankylosis)

Luxation injuries pose the greatest threat to pulp vitality by traumatizing the supporting structures and severing blood vessels entering the apical foramen. World Health Organization classification is used to describe traumatic injuries to teeth. There are five main types of luxation injuries: concussions, subluxations, lateral luxations, extrusive luxations and intrusive luxations.

Concussion and subluxation of the tooth generally cause minimal displacement and rarely result in damage to the pulp.WHO describes a tooth that has sustained a concussion injury as one that is sensitive to percussion but has not been displaced and is not abnormally mobile. A subluxated tooth demonstrates increased mobility but no displacement. The tooth with an open apex has a good prognosis with concussion and subluxation injuries.

With extrusive luxation, the tooth is very mobile because of the partial displacement out of the socket. Again, the immature tooth with an open apex has a significant advantage due to better access to the blood supply.

Inflammatory root resorption occurs in response to pulp necrosis and can be recognized radiographically when the resorptive defect on the root surface is separated from the bone by a radiolucency. In the case of the immature tooth, this indicates that the pulp is infected and immediate apexification is required. Removing the pulp should halt resorption. When radiographs indicate that resorption has ceased and the apex has closed, a permanent root filling material can be placed.

With intrusive luxation, the tooth has been forced apically and is embedded in bone. Intrusive luxations create the most serious challenge to maintaining pulp vitality, but in the case of the immature tooth, intervention is not always necessary. This differs from the recommendation for the mature, completely formed root where endodontic treatment is always recommended.

Lets look at another interesting case where no intervention was necessary. Six-year-old Sarah fell off her swing, and her mother brought her to the dentist two days later. The maxillary central incisors had erupted just a few weeks before the accident. Sarahs left central incisor was intruded subgingivally. The right central incisor was not traumatized, nor was it sensitive to percussion. The radiographs taken indicated the injured tooth had an apical diameter of 3mm.

Sarahs tooth was evaluated over a 12-month period. She was recalled at three weeks, three months, six months and 12 months. During that time, the tooth re-erupted and the root continued to develop. Sarah was fortunate that her tooths open apex allowed for revascularization. Again, in her case, no intervention was necessary.

Replacement resorption, commonly known as ankylosis, occurs when the trauma to the periodontal ligament triggers clastic cells to destroy cementum and dentin. Then the root structure is replaced by bone. Replacement resorption can be recognized on radiographs by the absence of a periodontal ligament separating the bone and the root. There is no known relationship between pulp vitality and replacement resorption, so root canal treatment is not effective in arresting the process of replacement resorption.