This document discusses the management of severely intruded permanent incisor teeth in children. It begins by defining intrusion as a form of tooth displacement deeper into the alveolus, which is more common in primary teeth. There is a lack of consensus on optimal treatment for intruded permanent teeth. Options include allowing spontaneous re-eruption, orthodontic repositioning, or immediate surgical repositioning. More severe intrusion is associated with higher risks of complications like pulp necrosis, root resorption, and ankylosis. Guidelines recommend different treatment approaches based on the degree of intrusion and root development. Long-term monitoring is important as resorption and infraocclusion can still occur. The case

1. MANAGEMENT OF
SEVERELY INTRUDED
PERMANENT INCISORS
CASE PRESENTATION AND
LITERATURE REVIEW
OSAMA ALKHALIFA

2. INTRUSION
Intrusion is a form of luxation
trauma that displaces the tooth
deeper into the alveolus. This
type of trauma occurs more
commonly in primary teeth and
the most frequent site is the
maxillary incisor area.

3. INTRUSION
It has a rarer occurrence in permanent
teeth and is considered one of the most
severe forms of luxation injury, because it
results in severe damage to the
periodontal ligament and alveolar socket

4. LUXATION
There are five subcategories of this type of
injury:
• Concussion: The tooth is sensitive to
percussion but has not been displaced and is
not abnormally mobile.
• Subluxation: The tooth has increased mobility
but has not been displaced. (A)
• Lateral luxation: The tooth has been
displaced and may be very firm. (C)
• Extrusive luxation: The tooth is very mobile
because of partial displacement out of the
socket. (B)
• Intrusive luxation: The tooth has been forced
apically and is firmly embedded in bone. (D)
Application of the international classification of
diseases and stomatology 3rd ed. Geneva:
World Health Organization; 1992

5. DIAGNOSIS OF INTRUSION IN
PERMANENT TEETH
Clinical findings:
• The tooth appears to be
shortened or, in severe cases, it
may appear missing.
• The degree of tooth intrusion is
recorded in millimetres. This
measurement represents the
distance between the incisal
edge of affected and unaffected
teeth

6. DIAGNOSIS OF INTRUSION IN
PERMANENT TEETH
Radiographic examination:
1- The degree of intrusion
2- The stage of apical
development
3- The presence of alveolar
bone or root fracture

7. TREATMENT OF INTRUSION IN
PERMANENT TEETH
There is a lack of general agreement and
scientific evidence concerning the best
treatment for traumatically intruded
permanent teeth in children.
Royal College of Surgeons of England
Clinical Guidelines 1997

8. TREATMENT OF INTRUSION IN
PERMANENT TEETH
There is no consensus reached on the
optimal treatment of intruded permanent
teeth.
Andreasen JO, Traumatic dental injuries
a manual, 1st edn. Copenhagen: Munksgaard; 1999

9. TREATMENT OF INTRUSION IN
PERMANENT TEETH
Treatment of traumatically intruded teeth is
based largely on empirical clinical
experience rather than on scientific data.
Stella Chaushu
American Journal of Orthodontics 2004

10. TREATMENT OPTIONS
1. Allowing spontaneous re-eruption of the
tooth (Passive repositioning)
2. Orthodontic repositioning (extrusion)
(Active repositioning)
3. Immediate surgical repositioning and
fixation (Immediate reduction)

11. COMPLICATIONS OF INTRUSION IN
PERMANENT TEETH
• Pulp necrosis
• Root canal obliteration
• External root resorption
• Marginal alveolar bone loss
• Gingival retraction

12. TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
• Extra-oral and intra-oral lacerations and
wounds should be cleaned and sutured as
appropriate.
• Systemic antibiotic treatment and tetanus
boosting may be required if external
contamination has occurred.

13. TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
• Repositioning of teeth with
incomplete apex
1. Mildly intruded (less than 3mm)
 Leave to re-erupt.
2. Moderately intruded (3-6mm)
 Leave to re-erupt.
 Orthodontic repositioning in approximately 2
weeks.
3. Severely intruded (greater than 6mm)
 Surgical repositioning.

14. TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
Repositioning of teeth with complete Apex
1. Mildly intruded (less than 3mm)
 Leave to re-erupt.
 Orthodontic repositioning in approximately 2 weeks.
2. Moderately intruded (3-6mm)
 Orthodontic repositioning in approximately 2 weeks.
3. Severely intruded (greater than 6mm)
 Surgical repositioning.

15. TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
Splinting of Surgically Repositioned Teeth
• non rigid splints
• The splinted tooth should be out of traumatic
occlusion.
• A review appointment should be arranged,
ideally within five days of the accident. At this
review the splint should be checked and
modified if necessary.
• Splinting for these injuries would normally vary
from 1 week to 2 weeks

16. TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
Root Canal Therapy:
In view of the very high risk of loss of
pulpal vitality, root canal treatment is often
indicated in cases of severe intrusion. The
optimum time to enter the root canal is
approximately 2 weeks after injury and
following thorough mechanical cleaning
and debridement, calcium hydroxide paste
should be placed in the canal.

17. TREATMENT OF TRAUMATICALLY INTRUDED
PERMANENT INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
1997
Root Canal Therapy:
Maintenance of calcium hydroxide paste in
the root canals for 6-12 months (with
appropriate replacement as required) is
advised, prior to the final obturation of the
root canal.

18. TREATMENT OF TRAUMATICALLY INTRUDED PERMANENT
INCISOR TEETH IN CHILDREN
GUIDELINES OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 1997
Follow-Up Management
• These cases should be kept under regular
review on a 6 monthly basis with
occurrences of root resorption being noted
and managed appropriately. Ankylosis as
evidenced by disappearance of the
periodontal space with fusion of root
surface and bone and is an unfavourable
sign.

19. EFFECT OF CALCIUM HYDROXIDE
The most important attribute of calcium
hydroxide is to create an unsuitable
environment for the continued survival of
bacteria in the pulp space or dentinal
tubules; less importantly, it raises the PH
to halt osteoclastic activity.
Hammarstrom
Endod Dent Traumatol 1986

20. EFFECT OF CALCIUM HYDROXIDE
There appear to be no benefit in leaving
calcium hydroxide in the tooth for a
prolonged period.
Dumsha
Int. Endo. J. 1995

21. EFFECT OF TETRACYCLINES
Tetracycline has been widely used in the
treatment of periodontal disease because of
its sustained antimicrobial effects. Recently,
tetracycline has been shown to possess anti-
resorptive, as well anti-microbial, properties;
specifically, it has a direct inhibitory effect on
osteoclasts and collagenase
Sae-Lim V et al
Endod Dent Traumatol 1998

22. Factors affecting resorption in traumatically
intruded permanent incisors in children
• There was a significantly earlier onset and
higher prevalence of resorption in more severely
intruded teeth
• The main factors increasing resorption were the
degree of intrusion and the stage of root
development. The treatment method did not
significantly affect the outcome.
Sondos Al-Badri et al
Dental Traumatology 2002

23. Factors affecting resorption in traumatically
intruded permanent incisors in children
No. of teeth
with root
resorption
Total no. of
teeth
Degree of intrusion
1 (14%)7< 3 mm
16 (59%)273 – 5 mm
19 (70%)27> 5 mm
Sondos Al-Badri et al
Dental Traumatology 2002

24. Factors affecting resorption in traumatically
intruded permanent incisors in children
No. of teeth
with root
resorption
Total no. of
teeth
Apical development
6 (26%)23Open
6 (60%)10Parallel
24 (86%)28Closed
Sondos Al-Badri et al
Dental Traumatology 2002

25. 5 years survival of intruded incisors
Incisors intruded >6mm (RCSE 3) had
significantly decreased survival than incisors
intruded <3 mm (RCSE 1) at five years.
Janice Humphrey 1999
A longitudinal outcome study of intrusive luxation injuries to
permanent maxillary incisors of children and adolescents
A thesis for the degree of Master of Science
University of Toronto

26. 5 years survival of intruded incisors
Severity of
intrusion
mm
Age
Years
No. of teeth
31
Range 0.5 – 12
Mean 5.3
Range 5.5 – 17.8
Mean 9.1
Survived
26 (84%)
Range 4.0 – 9.0
Mean 6.6
Range 9.2 – 12.3
Mean 10.8
Failed
5 (16%)
Janice Humphrey
1999

27. CILINICAL CASE
SEVERELY INTRUDED
PERMANENT MAXILLARY RIGHT
CENTRAL INCISOR

28. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
• A 13-year-old healthy male was brought 15
minutes after a fall at home which has
resulted in:
• A 13 mm intrusion of tooth 11 with
Complicated crown fracture
• Fracture of labial plate of alveolar bone
• Severe gingival laceration

29. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
18 mm

30. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
• The tooth was
immediately
repositioned, soft
tissue wound
sutured and tooth
splinted with
composite
5 mm

31. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
• The patient was prescribed amoxycillin
250 mg 6 hourly, metronidazole 250 mg
three times daily for 5 days and then
tetracycline HCL 250 mg for more 5 days.
Also analgesic and chlorhexidine
mouthwash were prescribed.
• The patient was advised to maintain good
oral hygiene.

32. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
• 6 days later pulp was
extirpated and calcium
hydroxide paste placed
in the canal and access
cavity closed with glass
ionomer

33. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
Splint was removed after 4 weeks

34. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
AFTER 2 MONTHS

35. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
AFTER 2 MONTHS

36. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
• Definitive root canal
treatment was
accomplished after
two months and one
week later a post
was inserted in the
canal and the crown
built up with
composite

37. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
IMMEDIATELY AFTER FINISHING TREATMENT

38. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
At 6 months the followings were noted:
• Gingival retraction
• Decreased tooth mobility
• High-pitched sound on percussion
• No infraocclusion
• Radiographically absence of PDL space
was seen

39. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
6 MONTHS AFTER FINISHING TREATMENT

40. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
6 MONTHS AFTER FINISHING TREATMENT

41. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
At 12months the followings were noted:
• Gingival retraction
• Decreased tooth mobility
• High-pitched sound on percussion
• Infraocclusion
• Radiographically absence of PDL space
was seen

42. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
12 MONTHS AFTER FINISHING TREATMENT

43. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
12 MONTHS AFTER FINISHING TREATMENT

44. SEVERELY INTRUDED PERMANENT
MAXILLARY RIGHT CENTRAL INCISOR
RADIOGRAPHIC CHANGES
1 week
2 months
6 months
12 months

45. ANKYLOSIS
Ankylosis is a pathologic fusion of the
cementum or dentin of a tooth root to the
alveolar bone
Andersson et al
Int J Oral Surg 1984

46. ANKYLOSIS
Clinically:
• Lack of tooth mobility
• Cessation of eruption
(infraocclusion)
• Characteristic high-pitched
sound on percussion

47. ANKYLOSIS
Radiographically:
• Absence of PL space
• Moth-eaten appearance
of the root

48. ANKYLOSIS
Management options:
• Early extraction followed by a series of
transitional prostheses
• Intentional luxation and surgical repositioning
• Decoronation (crown amputation)
• Ridge augmentation + implant-retained
prosthesis at skeletal maturity

49. ANKYLOSIS
The choice of treatment depends on the
severity of infraocclusion and replacement
resorption, the preference and experience
of the clinician and patient expectations.

50. Discussion
Thank you