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E2 ◊Page E1 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 3/2017 Figure 3 Figure 4a Figure 4b Figure 4c Figure 4d Figure 5 Figure 6 Figure 7 Figure 8 (Figure 3) The necrotic pulp was extirpated two weeks following the start of ortho- dontic treatment and a non-setting calcium hydroxide root canal fi lling material was placed for about three weeks. The aim of using the calcium hydroxide dressing material was to dissolve any pulp remnants, and to alkalinise the environment to mini- mise the infl ammatory root resorp- tion. [9] Then 0.014 and 0.016 inch NiTi wires (Ortho Technology Company) were used, in order to complete the alignment phase by moving the traumatised tooth back into its nor- mal and physiological position. The alignment phase took about three months, after which the tooth was normally positioned within the line of the arch. (Figure 4. a-d) The result was maintained with an upper fi xed lingual retainer (Ortho Technology) extending from upper right canine to upper left canine. (Figure 5, 6) By the end of treatment, the gingival margin of the affected tooth was not level with the contralateral central incisor (Figure 4:A); this may be the result of the rapid extrusive forces which were applied to the intruded tooth. A gingivectomy for the upper left central incisor was performed about one year later in order to level it with the gingival margin of the right central incisor. (Figure 7,8) Discussion Traumatic intrusion luxation is a serious type of injury, and it occurs most frequently in upper incisors. [4] Management of traumatically intruded permanent teeth differs according to the root apex maturity and the severity of the luxation in- jury itself. In case of mild intrusion of teeth with incomplete root forma- tion, the intruded teeth are given the chance to re-erupt spontaneously within three weeks. [10] [11] [12] If the intruded tooth does not erupt by itself during the three week ob- servation period, it is preferable to extrude the tooth, in order to replace it in the line of the arch. In our case, spontaneous re-eruption was not preferred because, accord- NOW AVAILABLE in all popular prescriptions, including the MCLAUGHLIN, BENNETT, TREVISI* RX! To learn more, visit ormco.eu, call 800-854-1741, or speak with your Ormco representative. © 2017 Ormco Corporation *Does not imply endorsement ing to the UK national clinical guide- lines, the chances of spontaneous re-eruption in mature teeth are low, especially if the intrusion is above 3 mm and, if eruption occurs, the tooth will not reach up to the prein- jury occlusal level.[12] [13] As a result, the authors preferred immediate orthodontic extrusion, aiming to minimise the chance of ankylosis. This concurs with Andrea- son, who states that orthodontic forces should be applied within the fi rst few days following the intrusive luxation injury. [14] The initial arch wire was thin with low force to mini- mise any heavy and non-physiologic loading on the luxated tooth). Endodontic treatment was manda- tory in our case, since the intruded tooth had a fully-formed root with completely closed apex. [7] The pulp was extirpated, to avoid the devel- opment of external root resorption, which can lead to tooth loss. [15] Sur- gical repositioning was not preferred because it usually produces severe trauma to the periodontal ligament, leading to replacement resorption and tooth loss. [16] Conclusion The application of immediate ortho- dontic extrusive forces to reposition the traumatically intruded upper left permanent central incisor was effective. Early tooth repositioning created easy access for pulp extirpa- tion which probably minimised the chances of external root resorption, ankylosis and hence tooth loss. Acknowledgements We have to thank Dr Majd Salameh for performing the endodontic treat- ment of the traumatically intruded upper central incisor References 1. Kaste LM, Gift HC, Bhat M, Swango PA Prevalence of incisor trauma in persons 6-50 years of age United States: J Dent Res. 1996; 75 Spec No: 696-705 1988-1991 2. Ellis RG, Davey KW The classifi ca- tion and treatment of injuries to the teeth of children. 5th Edn Chicago: Year book publishers Inc 1970 3. Andreasen JO Etiology and patho- genesis of traumatic dental injuries. A Clinical Study of 1298 Cases Stand J Dent Res 78:339-42 1970 4. Sarog˘lu I, So¨nmez H The preva- lence of traumatic injuries treated in the pedodontic clinic of An-kara Uni- versity, Turkey, during 18 months Dent Traumatol. 18:299–303 2002 5. Andreasen JO Luxation of perma- nent teeth due to trauma Stand J Dent Res 78: 273-286 1970 6. Wigen TI, Agnalt R, and Jacobsen I Intrusive luxation of permanent in- cisors in Norwegians aged 6–17 years: a retrospective study of treatment and outcome Dental Traumatology, vol. 24, no. 6, pp. 612–618, 2008 7. Andreasen FM, Pedersen BV Prog- nosis of luxated permanent teeth de- velopment of pulp necro-sis Endod Dent Traumatol 1:207-20 1985) 8. Andreasen FM Pulpal healing after luxation injuries and root fracture in the permanent dentition Endodon- tics & Dental Traumatology, vol. 5, no. 3, pp. 111–131, 1989 9. Siqueira Jr. JF and Lopes HP En- dodontia—Biologia e T´ecnica 3rd edition, Rio de Janeiro, Brazil: Guana- bara Koogan 2004 10. Bruszt P Secondary eruption of teeth intruded into the maxilla by blow Oral Surg Oral Med Pathol. 11:146-9 1958 11. Ravin Intrusion of permanent in- cisive Tandlaegebladet 79:643-6. 1975 12. Turley PK, Joiner MW, Hellstrom S The effect of orthodontic extrusion on traumatically intruded teet. Am J Orthod Dentofacial Orthop. 85:47-56 1984 13. Vahid Golpayegani M, Tadayon N A multidisciplinary approach to the treatment of traumatical-ly intruded immature incisors. A 6-year follow up Iran: Endod J. Winter; 1(4):151-5 2006 Epub 2007 Jan 20 14. Andreasen JO Traumatic injuries of the teeth Philadelphia: W.B. Saun- ders Company 1981 15. Oulis C, Vadiakas G, and Siskos G Management of intrusive luxation injuries, Endodontics and Dental Traumatology, vol. 12, no. 3, pp. 113– 119, 1996 16. Epker BN, Pandus PJ Root resorp- tion activity after replantation of mature permanent incisors in mon- keys Swed Dent J 4: 101-l 10, 1980 Surgical-orthodontic correction Emad Hussein Professor, Department of Orthodontics, Arab American University, Palestine Mohammed Jaradat Assistant Professor, Department of Or- thodontics, Arab American University, Palestine Alev Aksoy Associate Professor, Süleyman Demirel University, Department of Orthodontics, Isparta, Turkey Ahmad Hamdan Professor, Department of Orthodontics, University of Jordan, Amman, Jordan Fadi Khuffash Master in Aesthetic Dentistry, Private practice, Ramallah, Palestine