Tooth intrusion is associated with a potential risk of loss of the affected
tooth due to replacement resorption (ankylosis) or infection related
resorption. Treatment methods are only partly evidence based. Prognosis in all
cases is uncertain.
Surgical repositioning and fixation
This treatment technique is preferable in the acute phase and in permanent
teeth. Intrusion with major dislocation of the tooth (approximately more than
half a crown length) may indicate surgical repositioning.
This treatment may be preferred for patients coming in for delayed treatment
and enables repair of marginal bone in the socket along with the repositioning
of the tooth.
Await spontaneous eruption
This is the treatment of choice for deciduous/primary teeth and for teeth with
incomplete root formation.
Common for all treatments
Endodontic treatment is to prevent the necrotic pulp initiating
infection-related root resorption. This treatment should be considered in all
cases with completed root formation where the chance of pulp revascularization
is very minimal. Endodontic therapy should preferably be initiated within 3–4
Under local or general anesthesia, the tooth may be guided to it’s proper
position by means of an extraction forceps, and soft-tissue repair may precede
the fixation of the tooth. The tooth should be fixed after repositioning with
acid etch/resin technique in a manner that will promote healing of the
periodontal ligament, ie, no hard contact between tooth and bony socket.
Arch bar fixation is not recommended, since it implies displacement during
tightening of steel wires which further adds to the risk of trauma to the
periodontal ligament, with subsequent replacement resorption of the root.
Sequence of procedure
- Local or general anesthesia
- Surgical repositioning of the tooth
- Soft-tissue repair (if necessary)
- Fixation of tooth
- Aftercare and follow-up
If the injury occurred outdoors and the wound is contaminated with soil,
tetanus prophylaxis should be considered.
Repositioning becomes increasingly difficult with increasing depth of
intrusion of the tooth. In most cases a gingival laceration is present which
provides sufficient access to the tooth.
The tooth is pulled by the forceps and placed in its proper position.
When the tooth is in position, the neighboring displaced bone may be molded
to its proper position by digital pressure to promote healing.
In case of gross comminution of the alveolar bone and lacerations of soft
tissues, the tooth may temporarily be placed in saline solution while
remodeling the osseous tissues and repair the soft tissues by means of
The wound should be rinsed with saline solution if contaminated with foreign
bodies. Repair of tears should be completed before working with the acid
etch/resin technique. Drying of the tooth with compressed air or absolute
alcohol should be avoided in the presence of open wounds.
Monophilic nylon is preferred as a suture material in case of lacerated
gingiva or mucosa. Interrupted sutures are the standard of care of wound
closure in lacerated gingival wounds.
Fixation is preferably accomplished with acid etch of the incisal enamel and
application of a resin splint involving intact neighboring teeth. The teeth
involved are gently dried with compressed air (as illustrated) or absolute
alcohol and kept dry during the fixation procedure.
A finger on the lingual aspect of the tooth can maintain tooth position
during the fixation procedure.
Points of fixation in the repositioned tooth as well as neighboring teeth
are etched with phosphoric acid for 20 seconds.
Remember to place a suction tube to maintain dryness during etching
The etch gel is removed by saline irrigation. Make sure to direct the saline
jet in a direction away from soft-tissue wounds and to place a suction tube to
remove the spray of the saline and etch gel.
The fixation spots are then dried.
It is imperative that the enamel be kept dry until the resin has completely
Resin material (eg, as used for temporary crowns and bridges) is applied to
provide a splint. This material allows a certain flexibility of splinting and
is easy to remove.
Fixation should generally be maintained for 4 weeks in the case of intrusion
in order to allow healing of crushed or fractured bone.
Note: the patient should be put on soft diet for 2 weeks. Exposure to
temperature extremes should be avoided.
Note: care has to be taken that there is no occlusal loading to the affected
After the fixation period (4 weeks) the resin can be peeled off with a
dental scaler or removed with a burr. The tooth must be supported by digital
axial pressure during this procedure.
By means of orthodontic appliance anchored to neighboring two or preferably
more teeth on each side of the traumatized tooth, the intruded tooth may be
gently pulled towards its proper position by means of elastic traction. The
whole procedure requires at least 3–4 weeks. The force of extrusion should be
kept low, and the procedure requires a close follow-up scheme.
Application of bracket
The crown of the intruded tooth is exposed. After etching, rinsing, and
drying of the enamel surface of the intruded tooth, a bracket is bonded to the
After etching, rinsing, and drying of the enamel surfaces of at least two
neighboring teeth on each side of the intruded tooth, a metal thread is bonded
Elastic traction is established between the anchoring rod and the bracket on
the tooth. Elastics should be checked and replaced once a week until successful
repositioning has been achieved.
The repositioning needs at least 3–4 weeks. The force of extrusion should be
kept moderate, and the procedure requires a close follow-up.
Removal of fixation devices
The resin can be peeled off with a dental scaler or removed with a burr. The
tooth must be supported by axial digital pressure during this procedure.
Illustration shows completed repositioning.