Dental Traumatology - 2014 - AlKhalifa - Intrusive Luxation of Permanent Teeth A Systematic Review of Factors Important
Dental Traumatology - 2014 - AlKhalifa - Intrusive Luxation of Permanent Teeth A Systematic Review of Factors Important
Dental Traumatology - 2014 - AlKhalifa - Intrusive Luxation of Permanent Teeth A Systematic Review of Factors Important
12104
Intrusive luxation (intrusion) is the displacement of the The objectives of this systematic review were as fol-
tooth into the alveolar bone along the axis of the tooth lows: (1) to conduct a literature review of the topic
and is accompanied by comminution or fracture of the ‘intrusive luxation of permanent teeth’ and assess the
alveolar socket (1). Intrusion of permanent teeth is one current strength and level of evidence of the available
of the most severe dental injuries and usually occurs in studies; (2) to investigate the risks of complications of
children aged 6–12 years (2). This type of luxation is different treatment methods; and (3) to assess other
rare, comprising 0.3–1.9% of the traumas affecting per- important factors taken into consideration for the
manent teeth (1). Traumatic intrusion often affects a choice of treatment.
single tooth, especially the central or lateral incisor,
and is usually caused by falls where the tooth is hit
Review methods
and displaced into the bone (2). The pulp immediately
loses its vascular supply, and the periodontal ligament
Electronic searches
is severely injured. The prognosis of this injury is poor,
and severe complications predominate in the long term The search procedure is presented in Table 1 and
(1). However, there are reports that intruded teeth can Fig. 1. For OvidMEDLINEâ, under the permuted
heal and function normally, without leading to even- index search, the word ‘luxation’ was typed, the result-
tual tooth loss. ing subject heading ‘Tooth Avulsion’ was exploded,
Treatment for this type of trauma can be performed and the following subheadings were selected: drug ther-
either actively, by repositioning (surgical or orthodon- apy (/dt), economics (/ec), rehabilitation (/rh), surgery
tic extrusion), or passively, by spontaneous re-eruption. (/su), and therapy (/th). Searching involved a combina-
However, the choice of treatment is controversial in tion of controlled vocabulary and free text terms. One
the literature, and recommendations are often contra- review author performed the search strategy that iden-
dictory or unclear. tified 114 studies from the electronic databases.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 169
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170 AlKhalifa & AlAzemi
Ovid MEDLINEâ 1946 to August week 1, 2012, and Ovid MEDLINEâ In-Process & Other Non-Indexed Citations August 13, 2012 (112 references after
duplication removal, of which 70 were related to intrusive luxation of permanent teeth)
PubMed and Medline (www.ncbi.nlm.nih.gov, no date restriction) (no additional relevant study found)
Embase by Elsevier (https://www.embase.com) 1947 to July 13, 2013 (no additional relevant study found)
Cochrane Central Register of Controlled Trials June 2013 (zero studies)
Database of Abstracts of Reviews of Effects 2nd Quarter 2013 (zero studies)
Ovid MEDLINEâ Daily Update July 03, 2013 (zero studies)
System for Information on Grey Literature (www.opengrey.eu) in Europe 1997 to July 13, 2013 (zero studies)
The National Technical Information Service (http://www.ntis.gov, no date restriction) (one case report)
Cochrane Database of Systematic Reviews 2005 to May 2013, and Cochrane Oral Health Group Trials Register 1993 to July 1, 2013 (one systematic review,
which was not relevant)
Methodological quality assessment 7 studies did not meet the inclusion criteria, and
applied to 10 cohort studies were therefore excluded
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Systematic review of cohort studies 171
Table 2. Newcastle–Ottawa quality assessment scale for cohort studies (numbers and letters in parentheses correspond to the
options chosen in the scale available from the website, and the total number of asterisks corresponds to the overall quality of the
study) (14)
Study Selection Comparability Outcome
Al-Badri et al. (2002) (12) *** (1.b, 2.a, 3.a, 4.b) * (1.a) ** (1.a, 2.a, 3.c)
Stewart et al. (2009) (10) ** (1.c, 2.a, 3.a, 4.b) None **(1.d, 2.a, 3.b)
Andreasen et al. (2006) (3) *** (1.a, 2.a, 3.a, 4.b) ** (1.a and 1.b) *** (1.a, 2.a, 3.b)
Humphrey et al. (2003) (4) ** (1.c, 2.a, 3.a, 4.b) * (1.a) ** (1.a, 2.a, 3.c)
Ebeleseder et al. (2000) (8) *** (1.c, 2.a, 3.a, 4.a) None *** (1.a, 2.a, 3.b)
Neto et al. (2009) (9) ** (1.c, 2.a, 3.a, 4.b) None *** (1.a, 2.a, 3.b)
Wigen et al. (2008) (6) ** (1.c, 2.a, 3.a, 4.b) None *** (1.a, 2.a, 3.b)
Tsilingaridis et al. (2011) (11) *** (1.b, 2.a, 3.a, 4.b) * (1.a) *** (1.a, 2.a, 3.b)
Kinirons and Sutcliffe (1991) (7) ** (1.c, 2.a, 3.a, 4.b) None *** (1.a, 2.a, 3.a)
Bauss et al. (2010) (5) *** (1.c, 2.a, 3.a, 4.a) None ** (1.a, 2.a, 3.c)
Both Wigen et al. (6) and Tsilingaridis et al. (11) did treatment provided. This diversity was also evident in
not address the key outcome ‘marginal bone loss’ in their design and quality (methodological heterogeneity).
their studies, although this outcome was reported in Because of these diversities, a meta-analysis was not
most studies related to intrusive luxation, and there- performed. A test of heterogeneity, forest plots, and
fore, they were at high risk of reporting bias. In addi- some factors related to GRADE (15), namely inconsis-
tion, the penultimate study (6) reported pulpal necrosis tency and imprecision of results, could not be prepared,
and IRR in the results without prespecifying them in because the adjusted intervention effect estimates and
the ‘methodology’ section. Similarly, Tsilingaridis et al. the adjusted 95% confidence intervals could not be
reported tooth loss in the results without prespecifying obtained from the authors. Meta-regression analysis
it in the ‘methodology’ section. The Tsilingaridis study was also not possible because of the small number of
was also at an unclear risk of misdiagnosing pulpal studies included (fewer than 10). There was a very low-
necrosis, because there was a chance that it was quality body of evidence for each outcome when
detected based on insensitivity to electric pulp testing GRADE (15) was used to evaluate the included obser-
and crown discoloration alone (11). Andreasen et al. vational studies, mainly due to bias, and the indirect-
(2) did not record probing depths in the initial visit, ness of evidence across studies: In the study by
leading to an unclear risk of selection bias for marginal Andreasen et al. (2), spontaneous re-eruption was
bone loss. restricted primarily to teeth with immature roots, and
this passive approach was not attempted for those
above 17 years of age. Furthermore, in the study by
Results
Wigen et al. (6), most of the included patients were up
The included studies (3, 6, 11) showed clear clinical to 12 years of age, and spontaneous eruption was
diversity (clinical heterogeneity) between them due to restricted mainly to immature teeth, whereas in the
variability in the characteristics of participants, study conducted by Tsilingaridis et al. (11), most of the
outcomes studied, and factors associated with the teeth that were severely intruded with full root
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172 AlKhalifa & AlAzemi
Andreasen et al. (2006) (3) This was a retrospective prospective study conducted in Denmark. The progression of spontaneous eruption was followed
at 1- to 2-month intervals. Follow-up period was for at least 1 year. There were 114 patients aged 6–67 years.
The number of re-erupted teeth was not reported.
Wigen et al. (2008) (6) This was a retrospective study conducted in Norway. Follow-up period ranged from 1 to 12 years. There were 39 patients
aged 6–17 years. Forty-one percentage of the teeth were completely intruded. Orthodontic extrusion was delayed for
1–8 months for 71% of the teeth in the orthodontic treatment group.
Tsilingaridis et al. (2011) (11) This was a retrospective study conducted in Sweden. Follow-up period varied from 6 to 130 months. There were 48 patients
aged 6–16 years. Seventeen percentage of the teeth in the orthodontic extrusion group were luxated with the fingers
before extrusion. Sixteen percentage of the teeth in the surgical repositioning group were extracted and replanted.
formation were restricted to the surgical repositioning 6, 11). This minor difference was also found when
group. Thus, the following comparisons should be marginal bone loss and tooth loss were measured in
interpreted with caution. the study conducted by Andreasen et al. (3).
Spontaneous re-eruption resulted in the fewest com-
plications (RRR, IRR, and pulpal necrosis) as refer-
Discussion
enced from the three studies (3, 6, 11) and illustrated in
Fig. 3, with RRR being the main reason for tooth loss Currently, all studies for the treatment of traumatically
(6). There were slight differences in the total re-erup- intruded permanent teeth have limitations. Guidelines
tion times (Fig. 4). Spontaneous eruption had a high for treatment are currently not based on strong
success rate, with 12% of the teeth failing to re-erupt evidence.
because of RRR and apical bone ingrowth in pulp
canals, as reported by Tsilingaridis et al. (11), and 5%
Discussion of methods: risk of bias analysis
of the teeth failing to re-erupt because of RRR,
as reported by Wigen et al. (6). Andreasen et al. (3) Currently, there are no available randomized, con-
reported that spontaneous re-eruption caused less mar- trolled trials, probably because it would be unethical to
ginal bone loss and tooth loss, compared with that randomize treatment in an emergency setting, at least
caused by surgical and orthodontic repositioning. How- in cases of severe intrusion. In this review, only cohort
ever, these two outcomes were not reported in each studies were included because they are methodologi-
intervention group in the other two studies (6, 11). cally higher in quality (if not downgraded) compared
Very little difference was found between surgical with case reports, case series, and in vivo and in vitro
repositioning and orthodontic extrusion in relation to laboratory studies. Furthermore, including the same
pulpal necrosis, IRR, and RRR in the three studies (3, type of studies in a review is needed to make a
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Systematic review of cohort studies 173
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174 AlKhalifa & AlAzemi
confounded by the fact that, by definition, young peo- for the superiority of either surgical or orthodontic repo-
ple have immature roots (16). Age was more strongly sitioning in terms of the fewest complications.
related to marginal bone loss than to root develop-
ment, with more bone loss identified in older people,
Implications for research
perhaps because their bone is more dense and they
have fewer healing capabilities compared with young It is important that high-quality observational studies
individuals (16). be conducted with sufficiently high numbers of
patients. Perhaps this can be accomplished by involving
Important factors in risks of complication in different
trauma centers that use a standardized method. Fur-
treatment methods
thermore, weaknesses of studies previously reported in
this review—namely blinding of outcome assessment,
Spontaneous re-eruption reporting bias, and selection bias due to confounding—
The included studies (3, 6, 11) indicated that spontane- should be given a higher level of importance. Finally, it
ous re-eruption seemed to be associated with the fewest is recommended that future investigators specify out-
healing complications in a similar age group (6– comes not present at the start of the study, because this
17 years) compared with active repositioning, given form of selection bias was common in the studies
that endodontic access can be granted when needed. In reported in this review.
contrast to conclusions from the previous three
included studies, the animal studies (17–19) and one
cohort study (4) concluded that leaving traumatically Acknowledgements
intruded teeth in tight approximation to the bone Professor Lars Andersson is thanked for his significant
increased the risk of RRR. contribution to this review. Dr Abdulhamied Al-Fad-
Access for endodontic treatment in spontaneous re- dagh’s assistance is also appreciated. This review was
eruption can be performed by gingivectomy, even in supported by the Health Sciences Center Library
cases of very deep intrusion (6, 9, 20). However, An- Administration of Kuwait University.
dreasen et al. (3) suggested that spontaneous eruption
might fail due to mucosal closure when the tooth is
intruded at or below bone level. In the included studies Conflict of interest
(3, 6, 11), all patients awaiting spontaneous eruption None declared.
were in a restricted age group (6–17 years), and there-
fore, there is insufficient evidence for awaiting re-erup-
tion in people aged more than 17 years. References
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