Conservative treatment in adult patient with reimplanted anterior teeth after traumatic avulsion with extensive bone loss: an 8-year follow-up

ABSTRACT Introduction: Orthodontic treatment in patients with traumatized teeth is a condition that needs good planning in order to achieve satisfactory results. Objective: To discuss approaches to orthodontic treatment of malocclusions associated with trauma followed by avulsion of anterior teeth, reimplanted after a short period of time. Case report: The treatment started with the distalization of upper posterior teeth, with the aid of mini-implants and sliding jigs, followed by the inclusion of anterior teeth in the arch, followed by intrusion of these teeth. Results: With the treatment, improved mobility of the anterior teeth was achieved, with better insertion into bone tissue. The most important factor for satisfactory treatment and a good prognosis for avulsion is the time the tooth remains outside the socket. Orthodontic treatment in patients with traumatized teeth is not contraindicated; however, clinical and radiographic aspects must be considered. Conclusion: Among the feasible orthodontic treatment options, the conservative approach can be a very favorable treatment alternative.


INTRODUCTION
The number of adult patients who seek orthodontic treatment increases every day. 1 Advancements in esthetics and comfort of orthodontic appliances has boosted the demand for this treatment. 2,3 Adult patients have some peculiarities that are inherent to their past history that make their treatment unique. 4,5 Missing teeth, periodontal disease, and traumatized teeth are not uncommon among these patients. 6 Traumatic injuries to permanent incisors and their supporting structures constitute a true dental emergency and require immediate assessment and management. 7 Among traumatic dental injuries, avulsion is one of the most severe, and its prognosis is closely related to the actions taken from immediately after avulsion to tooth reimplantation. 8,9 Tooth reimplantation is considered a conservative treatment aimed at reinserting the avulsed tooth into the socket, but several factors should be taken into account in order to achieve an acceptable outcome. 10 Time out of the socket is the most important factor for satisfactory treatment of avulsion and for a good prognosis; therefore, the tooth has to be reimplanted immediately, so that its functions can be preserved. 10,11 Pithon MM -Conservative treatment in adult patient with reimplanted anterior teeth after traumatic avulsion with extensive bone loss: an 8-year follow-up 5 Orthodontic treatment in patients with traumatized teeth is not contraindicated; however, clinical and radiographic examination of the repair and/or complications after the traumatic injury should be performed before treatment. 12,13 Accordingly, the aim of the present study is to report a clinical case of an adult patient with generalized bone loss whose anterior teeth had been avulsed after a fall and reimplanted, with subsequent orthodontic tooth movement for Class II malocclusion correction.

DIAGNOSIS
Female patient, aged 49 years and 1 month, was referred by an implant dentist, who recommended malocclusion correction for later prosthetic rehabilitation of her missing posterior teeth and traumatized anterior teeth (Fig 1). The patient reported "slipping in the shower about 10 months before, and feeling her anterior teeth falling right out of her mouth." The patient's general health status was good, but her oral health was poor, since the following tooth elements were missing: #17 (maxillary right second molar), #36 (mandibular left first molar), and #46 and #47 (mandibular right first and second molars). The patient had extensively restored teeth and anterior teeth with large gingival recession, with history of trauma followed by avulsion of teeth #11, #21, and #22 (maxillary central incisors and maxillary lateral incisor). A full orthodontic workup was requested prior to the treatment.    The radiographic examination revealed generalized bone loss, which was quite pronounced in maxillary incisors, maxillary right first molar (#16), and mandibular left second molar (#37).

TREATMENT OBJECTIVES
The treatment objectives of the present clinical case were as follows: creation of space in dental arches for orthodontic tooth movement; bilateral Class II relationship correction; bimaxillary protrusion correction; uprighting of mandibular molars, opening space for dental implants; intrusion and distalization of maxillary right first molar (#16); and maintenance and intrusion of traumatized maxillary incisors. were placed for relief in the maxillary anterior region (Fig 7), whereas a 0.018 x 0.025-in archwire was placed in the lower arch.    After creating a space in the maxillary left anterior region, the left lateral incisor (#22) was released from the splint and the orthodontic bracket was bonded. At this stage, another 0.020-in passive archwire was bent in this region and tooth #22 was included (Fig 11).
This tooth had moderate mobility (grade 2). The splint was removed after 60 days and tooth movement was then checked. This stage of treatment caused a lot of concern, since the teeth had greater   Meanwhile, in the lower dental arch, spaces were closed, tooth alignment and leveling were carefully adjusted, and the mesially inclined molars were uprighted.
Thereafter, mini-implants were placed between maxillary premolars ##14/15 and #24/25, which served as support for closure of maxillary spaces, with posterior and maxillary repositioning (Fig 14). Note that, from the beginning of alignment and leveling, the anterior teeth became more intruded, improving their relationship with the other teeth and with the bone base (Fig 15). After 36 months of treatment, the orthodontic appliance was removed, with subsequent placement of a 3x3 intercanine retainer. A wraparound retainer was used in the maxillary dental arch, in association with a fixed retainer between the maxillary central incisors and the maxillary right lateral incisor (#12 and #21) (Fig 15).
The patient was referred to a prosthetist for replacement of provisional prostheses on anterior teeth by definitive ones, in addition to periodontal follow-up. The prosthesis on the anterior teeth kept them together despite of extensive bone loss.

TREATMENT RESULTS
At the end of the orthodontic treatment, there was enough space for accommodation of teeth, good intercuspation, with overbite and bilateral Class II malocclusion correction. The mandibular molars were uprighted, creating space for the placement of osseointegrated implants. Esthetically, smile harmony and positioning of the teeth were enhanced (Fig 15). The anterior teeth were intruded, substantially improving mobility, which went from grade 3, in central incisors and right lateral incisor, to grade 1 (Figs 16 and 17).     (Figs 18 and 19).
Eight years after removal of the fixed orthodontic appliance, the improvements achieved with its use were maintained (Fig 20), as it can be analyzed in the photographic and radiographic records (Figs 20 to 24 and Table 1).

DISCUSSION
The aim of the present study was to describe the conservative orthodontic treatment of a patient with Class II malocclusion whose anterior teeth had been reimplanted after their avulsion during a fall. The traumatic injury to the teeth might have been due to pronounced overjet (5 mm at baseline). According to Nguyen et al, 14 individuals with an overjet greater than 3 mm have twice the risk for injury to their anterior teeth than those with an overjet of less than 3 mm.
Dental avulsion is characterized by total detachment of the tooth from its socket and accounts for approximately 0.5% to 16% of dentoalveolar injuries to permanent teeth. 15 The time between avulsion and reimplantation, as well as where the tooth was kept during this period, are crucial for the prognosis, which is oftentimes poor.
The patient described in this study reported that her teeth had been knocked out of her mouth and fallen to the floor after she had slipped in the shower. She also reported being unconscious for about 5 minutes and receiving first aid from a public emergency service before being taken to hospital, where a dentist reimplanted her teeth. On the way to the hospital, her teeth were kept in physiological saline, which is considered as the best transport medium. 16 The time between Pithon MM -Conservative treatment in adult patient with reimplanted anterior teeth after traumatic avulsion with extensive bone loss: an 8-year follow-up 26 the traumatic injury and tooth reimplantation was shorter than 1 hour, and her teeth was maintained in physiological saline throughout. As recommended by Donaldson and Kinirons, 17  For optimum results, intrusion should be performed with light forces, and the line of action of the force should pass close to the center of resistance. 20 Light forces were used during intrusion. As mentioned earlier, alignment and leveling were performed with a passive stainless steel archwire, which was progressively adjusted as the teeth responded to orthodontic movement. After full alignment, orthodontic mini-implants were placed and used as support for space closure and intrusion. The mini-implants were placed between the premolars in a position that allowed the line of action of the force to be inclined upward, with anterior distalization Nevins and Wise 22 concluded that orthodontically moving teeth into infrabony defects might modify the defect's morphology, reduce probing depth, and resolve the bony defect.
This finding was described by Pithon 23 for orthodontic movement of anterior teeth with extensive bone loss and also in the present clinical case. Better insertion was clinically evident, since in the new position the teeth showed lower mobility than at the beginning of orthodontic movement.

CONCLUSIONS
The option of orthodontic treatment with a conservative approach can be a very favorable treatment alternative in malocclusions associated with trauma followed by avulsion of anterior teeth that are reimplanted after a short time.