Intrusive luxation in permanent teeth

PDS scores at follow up showed gains were maintained

Dental trauma affects around 1 in 4 school-age children. Intrusive luxation, defined as the axial dislocation of a tooth into its alveolus is a severe injury accounting for between 0.5-2% of dental trauma events in the permanent dentition.  Treatment options include, spontaneous re- eruption, orthodontic re-positioning, and surgical re-positioning.

The aim of this review was to identify the appropriate treatment for teeth with intrusive luxation.

Methods    

Searches were conducted in the Medline, Embase, the US Clinical Trials and ISRCTN Registry databases.  Interventional and observational studies comparing the outcomes of orthodontic or surgical re-position of intrusive luxation of permanent teeth compared with spontaneous re-eruption were considered.   Two reviewers independently selected studies, abstracted data and assessed risk of bias.

Root resorption was the primary outcome with marginal bone defects and pulpal changes as secondary outcomes.   Risk ratios (RR) with 95% confidence intervals (CI) were used to compare outcomes with meta-analysis being conducted when 3 or more studies were available.

Results

  • 8 studies involving a total of 440 patients were included.
  • Patients ages ranged from 6-67 years with some having more than one tooth traumatically intruded.
  • All of the studies were considered to be at high risk of bias.
  • Meta-analysis of 4 studies comparing surgical re-positioning vs. spontaneous re-eruption suggested no significant difference RR=1.30 (95%CI; 0.90–1.88) P = 0.16
  • Several meta-analysis for secondary outcomes were conducted (see tables below)
   No. of studies Marginal bone defects

RR (95%CI)

Probability
surgical re-positioning vs. spontaneous re-eruption 5 3.15 (1.68– 5.89) 0.0003
orthodontic re-positioning vs. spontaneous re-eruption 3 0.19 (0.06– 0.54) 0.002
surgical re-positioning vs. orthodontic re-positioning 3 1.29 (0.77–2.16) 0.03

 

  No. of studies Pulpal changes

RR (95%CI)

Probability
surgical re-positioning vs. spontaneous re-eruption 5 1.35 (1.14–1.60) 0.0005
orthodontic re-positioning vs. spontaneous re-eruption 4 0.69 (0.56–0.84) 0.0003
surgical re-positioning vs. orthodontic re-positioning 4 0.99 (0.87– 1.13) 0.80
  • A number of sub-group analyses were also conducted.

Conclusions

The authors concluded:-

The results of this systematic review and meta-analysis suggest that, whenever possible, spontaneous re-eruption should be the treatment of choice. When spontaneous re-eruption is not indicated, there is no difference between orthodontic and surgical re-positioning in terms of the positive outcome rates. The degree of root formation is important to the prognosis of the teeth, where teeth with incomplete root formation display a better prognosis.

Comments

The authors searched a couple of major databases and included a range of study designs but while a number of key details from the included studies are presented the type of study design in not presented.  The authors indicated that they were including both interventional and observation studies although they chose to assess study quality using the Cochrane Risk of Bias tool which is primarily designed for randomised controlled trials. As none of the included studies were randomised the studies this is not the most appropriate tool.  A large number of meta-analyses and sub group analyses were conducted and given the concern that the authors note regarding the quality of the studies and the small number of small studies that could be included the value in this level of detail analysis should be queried.

While this review appears to summaries what available evidence there because of the limited quality of the available studies these findings should be interpreted very cautiously.  In 2013 a Cochrane review by Belmonte et al ( Dental Elf- 1st May 2013) looked at treatments for luxated teeth and found no trials  noting that existing

clinical guidelines are based on available information from case series studies and expert opinions.

The Cochrane reviews also noted that undertaking clinical trials in this area are difficult but not impossible and would need researchers to collaborate to conduct well-designed clinical trials.

Links

Primary paper

Costa LA, Ribeiro CC, Cantanhede LM, Santiago Júnior JF, de Mendonça MR,Pereira AL. Treatments for intrusive luxation in permanent teeth: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2016 Sep 17. pii:S0901-5027(16)30212-0. doi: 10.1016/j.ijom.2016.08.021. Review. PubMed PMID:27649968.

Other references

Original review protocol on PROSPERO

Dental Elf – 1st May 2013

Review finds no trials to inform the treatment of displaced luxated permanent teeth

 

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