Management of chronic luxated central incisor with hopeless prognosis
A 16-year-old boy reported, with a chief complaint of mobile upper front teeth. His dental history revealed history of trauma 8 months back. Trauma led to avulsed maxillary right central incisor (11), extrusively luxated displaced out of the arch with Grade III mobility maxillary left central incisor (21), fractured (Ellis Class III) left lateral incisor (22) [].\nPulp sensibility was performed and both left central and lateral incisor (21, 22) were found to be nonresponsive. Intraoral radiographs revealed severe bone loss with respect to maxillary left elicited with right lateral incisor (12). Fremitus test was found to be negative. Case was diagnosed as primary endo and secondary perio lesion. The prognosis of tooth (21) appeared to be hopeless. Hence, extraction was advised for the left central incisor (21), which was extruded, non-responsive and had severe bone loss. Various replacement options such as RPD and implant were suggested to patient, but patient was keen on retaining his natural tooth and had financial constraints.\nHence, intentional replantation was considered as a treatment option. The probable outcome of treatment and complication were explained to patient and written consent was obtained.\nThe main goal of treatment was to achieve a conservative approach and thereby fulfill the individual's requirement. Treatment plan consisted of Phase I therapy followed by endodontic treatment, which was to be followed by intentional replantation.\nPhase I therapy was performed and patient was posted for endodontic treatment. Calcium hydroxide dressing was given for 2 weeks followed by obturation with Gutta percha.[] Surgery was planned 1 week after completion of endodontic treatment.\nLocal anesthesia (2% lignocaine HCl with 1:80000 adrenalines) was administered. Full thickness mucoperiosteal flap was reflected. On flap reflection, severe bone loss extending more than 2/3rd root length on palatal aspect was seen []. Tooth was atraumatically extracted and was immediately placed in a solution of tetracycline (500 mg of tetracycline dissolved in 20 ml saline) for a period of 5 min[] and was then transferred to a solution of sodium fluoride (0.05% w/v) for a period of 5 min [Figures and ]. After degranulation and curettage, PRF was prepared.\nA total volume 10 ml of blood was withdrawn, which was immediately centrifuged at 3000 rpm for preparation of PRF.[] PRF obtained was mixed with nano hydroxyapatite (HA) crystals and was placed in the tooth socket and bony defect. The tooth was replanted and aligned []. Flap was repositioned immediately and sutured using 3-0 silk sutures. Fiber reinforced composite resin splinting was done, periodontal pack was applied. Patient was put on amoxicillin 500 mg tid for 5 days and a combination of aceclofenac and paracetamol bid was given for 3 days. Mouthwash containing 0.2% chlorhexidine was advised from the day following surgery. Patient was recalled after 1 week for suture removal, revealed satisfactory healing was seen.\nIntraoral periapical radiograph (IOPAR) using long cone technique was taken to ascertain alignment of the tooth [Figures and ]. Oral hygiene instruction was reinforced and strict instruction not to bite on anterior teeth was given. Patient was put on regular recall visits.\nPatient was recalled after 2 months and it was observed that there was a significant reduction in in probing pocket depth. Radiograph taken revealed radiopacity in periapical area suggestive of periodontal repair or regeneration [].\nIn 3rd month, IOPAR has taken revealed significant radiopacity in periapical area []. Splint was removed. Mobility was found to be remarkably reduced to Grade I with a significant reduction in probing pocket depth. As mobility was reduced and patient was comfortable, esthetic correction was planned. Right central incisor (11) had avulsed and the left central incisor (21) had migrated toward midline so, a composite buildup of right lateral incisor (12) was performed. This was followed by restoration of Ellis Class III fractured 22, using post-placement followed by composite buildup []. Furthermore, lingual splint was placed in the region of 22 and 21 [].\nPatient was satisfied with the esthetic outcome. Patient has been followed-up for 6 months and so far the treatment outcome has been found to be esthetically and functionally satisfactory.