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CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 226-229

Surgical repositioning of a pathologically displaced central incisor with a large cystic lesion


Department of Conservative and Endodontics, SVS Institute of Dental Sciences, Mahabubnagar, Telangana, India

Date of Web Publication10-Oct-2016

Correspondence Address:
Udayakumar Palaniswamy
SVS Institute of Dental Sciences, Appanapally, Mahabubnagar, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.191836

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  Abstract 

Apical cyst development is one of the late sequels of trauma to teeth, which can make the treatment challenging. Till the time the condition becomes symptomatic or gets noticed by the surgeon, displacement of the involved tooth with increase in the size of the lesion may occur. This report presents the case of a 30-year-old female patient with a large cystic lesion around the maxillary right central incisor, along with malpositioning. Root canal treatment was performed followed by enucleation of the cystic lining. Intentional luxation and repositioning of the tooth in a more favorable position were performed and it was splinted for 4 weeks. On regular follow-up, the patient showed no symptoms with bony healing of the cystic cavity and reduction in tooth mobility.

Keywords: Luxation, repositioning, splinting


How to cite this article:
Palaniswamy U, Kaushik M, Singh K, Arya S. Surgical repositioning of a pathologically displaced central incisor with a large cystic lesion. J NTR Univ Health Sci 2016;5:226-9

How to cite this URL:
Palaniswamy U, Kaushik M, Singh K, Arya S. Surgical repositioning of a pathologically displaced central incisor with a large cystic lesion. J NTR Univ Health Sci [serial online] 2016 [cited 2019 Dec 14];5:226-9. Available from: http://www.jdrntruhs.org/text.asp?2016/5/3/226/191836


  Introduction Top


Traumatic dental injuries (TDIs) are the most common of the oral injuries,[1] and comprise 5% of all injuries for which people seek treatment.[2] Among the dental injuries, crown fractures and luxations occur most frequently.[3] The pulpal complications that commonly occur after dental trauma can be pulp canal obliteration, pulp necrosis with color changes in the crown, and internal resorption.[1] These make the endodontic procedure challenging. Sometimes, cyst-like lesions may also develop because of traumatic injuries to teeth. Many treatment options, including apical surgery, have been proposed for managing such cases.[4]

The success rate of the surgical approach using traditional means is in the range of 40-90%. By the use of recent endodontic surgical armamentarium, this rate has been elevated to 96.8%.[4]

However, Zuolo et al. stated that these favorable postsurgical outcomes were possibly affected by the site of surgery, as reported to be 97% in the maxillary anterior region compared to 85% in the posterior region due to a complex root anatomy in the latter.[5]

The challenge in cases where large lesions are associated with the displacement of the associated teeth to abnormal positions is to decide whether to retain or extract the tooth.

Extraction of the teeth can be advised in severe pathological malpositioning but while treating anterior teeth, aesthetics is the prime concern for the patient. Keeping this in mind, the treatment plan may be modified.

Intentional replantation and immediate repositioning are still considered as good options for traumatically malpositioned teeth.[6] Immediate surgical repositioning of the laterally displaced tooth and splinting with flexible splints for 4 weeks constitute the proposed treatment plan advised by some authors.[7]

This case report demonstrates a favorable clinical outcome of a large periapical cystic lesion induced by trauma, in the maxillary anterior region, along with malpositioning of the central incisor using a combination of the conventional endodontic treatment and surgical intervention.


  Case Report Top


A 30-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of discolored and rotated upper right front tooth [Figure 1].
Figure 1: (a and b) Preoperative photographs of the patient showing brown discoloration and lateral luxation of 11 compromising aesthetics of the patient c) Maxillary occlusal view showing periapical lesion extending from the central incisor to the first premolar and displacing the root of the central incisor distally

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The patient gave history of trauma in childhood, which was followed by intermittent episodes of pain that subsided after some time. No history of previous treatment was reported. Medical history was noncontributory.

On examination, mild swelling was noticed near the base of the nose on the right side of the face that was hard and slightly tender on palpation. The crown of the right central incisor was discolored, displaced mesially with slight rotation and grade II mobility. After taking panaromic, maxillary occlusal, and periapical views, a large radiolucency extending from the right central incisor to the right premolar was noticed. Pulp vitality tests were performed for all the teeth associated with the lesion. The incisors and canine showed no response while the premolar showed a delayed response.

A provisional diagnosis of the periapical cyst of endodontic origin was made.

Procedure

Conventional root canal treatment was performed from the central incisor to the first premolar 1 day prior to the surgery. The lesion was approached surgically following all the protocols of surgical endodontics and a full-thickness mucoperiosteal flap was raised from 21 to 14 [Figure 2]a.
Figure 2: (a) Flap raised (b) Cyst removed (c and d) tooth was intentionally luxated with the help of surgical forceps and splinted in new position

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The cyst lining was removed completely [Figure 2]b and sent for histopathological examination, which later confirmed the diagnosis of a radicular cyst. Cold burnishing was performed for the root canal-treated teeth for proper apical seal. 11 was luxated with a surgical forceps, taking care not to remove the tooth out of the socket and placed in a new position [Figure 2]c and [Figure 2]d. The flap was sutured back.

Splinting was performed with a 21-gauge orthodontic wire (Konark ever bright stainless steel wire, India) to stabilize the tooth and postoperatively, the patient was instructed to have a soft diet and maintain a proper oral hygiene.

The sutures were removed after 1 week. After 1 month, the splint was removed and the patient was asymptomatic. On 3-month follow-up, the lesion showed initiation of bony healing, no abnormal mobility, and healthy periodontal attachment.

Metal ceramic crown was placed over 11 [Figure 3]a and postendodontic composite restorations were performed for 12, 13, and 14. Three-months and 1-year follow ups show reduction in size of the lesion and bone regeneration [Figure 3]b and [Figure 3]c.
Figure 3: (a and b) Permanent crown cemented and 3-month follow-up showing progressive bony healing of the lesion (c) Maxillary occlusal view showing bony healing on 1-year follow-up

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  Discussion Top


Radicular cysts being the most common inflammatory jaw cysts (around 60% of all jaw cysts are radicular or residual cysts)[8] represents a chronic inflammatory process and develops only over a prolonged period of time. The main cause is pulpal necrosis, which can occur due to dental caries, trauma, or thermal injury during dental procedures.[9]

Most of the radicular cysts are symptomless. The teeth, which are associated are nonvital and may show discoloration. The patient may complain of slowly enlarging swelling or the cyst may displace the adjacent teeth or cause mild root resorption.[10]

To manage a large periapical lesion, treatment options range from nonsurgical root canal treatment to apical surgery or extraction. Some professionals opt for a conservative approach and support that if the endodontic infection is eliminated, the immune system will be able to promote lesion repair. However, many visits for application of intracanal medicament are required for this treatment option.[5] If the root canal space is nicely mechanically instrumented and obturated adequately, it is possible to eliminate the source of irritants and thus, a retrograde filling is not necessary,[11] whereas others believe that for a large lesion endodontic treatment alone is not sufficient and it should be associated with surgical intervention to completely remove the cystic epithelium.[12]

The treatment objectives in this case were to optimize oral health as well as to maintain function and aesthetics, along with comfort of the patient. The challenges were to maintain the aesthetics despite and at the same time treating a large lesion and there were higher chances of lesion recurrence and periodontal breakdown.

The treatment options that were considered for the present case were:

  1. Decoronating the crown and rehabilitation with post and core. This could compromise aesthetics and weaken the tooth structure as the direction of post and the core would be different with respect to the long axis of the tooth.
  2. Extraction of the tooth followed by replacement with an implant/removable or fixed partial denture was ruled out due to poor bone support and even the labial fullness would have got compromised due to alveolar collapse in this case.
  3. As the periodontal support was compromised, orthodontic repositioning of the tooth was not considered.
  4. Surgical intervention was necessary due to the large size of the lesion, with the radiographic appearance suggesting that the lesion was cystic and the long-lasting nature of infection.


Intentional luxation with surgical repositioning had many advantages. If successful, the natural tooth aesthetic can be maintained with one-stage operative treatment and if unsuccessful, coronal amputation and prosthesis can still be an option. In both the surgical treatment options, bone levels can relatively be preserved. In this case, procedure was undertaken with the knowledge that the luxated and surgically repositioned tooth could get ankylosed in its new position after bony healing of cystic cavity.


  Conclusion Top


Treatment for the present case was considered after evaluating all the factors that fully satisfied the patient needs and was conservative in approach. Surgical repositioning of a pathologically displaced tooth is a good treatment option when aesthetics are of prime importance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Andreasen JO, Andreasen F, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Oxford: Blackwell Munksgaard; 2007.  Back to cited text no. 1
    
2.
Petersson EE, Andersson L, Sorensen S. Traumatic oral vs non-oral injuries. Swed Dent J 1997;21:55-68.  Back to cited text no. 2
    
3.
Glendor U, Halling A, Andersson L, Eilert-Petersson E. Incidence of traumatic tooth injuries in children and adolescents in the county of Västmanland, Sweden. Swed Dent J 1996;20:15-28.  Back to cited text no. 3
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4.
Kim S, Kratchman S. Modern endodontic surgery concepts and practice: A review. J Endod 2006;32:601-23.  Back to cited text no. 4
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5.
Zuolo ML, Ferreira MO, Gutmann JL. Prognosis in periradicular surgery: A clinical prospective study. Int Endod J 2000;33:91-8.   Back to cited text no. 5
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6.
Nelson-Filho P, Faria G, Assed S, Pardini LC. Surgical repositioning of traumatically intruded permanent incisor: Case report with a 10-year follow up. Dent Traumatol 2006;22:221-5.  Back to cited text no. 6
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7.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al.; International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol 2007;23:66-71.   Back to cited text no. 7
    
8.
Joshi UK, Patil SK, Siddiqua A. Nasopalatine cyst a rare entity. Int J Dent Clin 2010;2:34-6.  Back to cited text no. 8
    
9.
Dunlap C. Cysts of the Jaws. Kansas City, Missouri, USA: University of Missouri-Kansas City (UMKC) School of Dentistry; 2000. p. 2.  Back to cited text no. 9
    
10.
Manwar NU, Agrawal A, Chandak MG. Management of infected radicular cyst by surgical approach. Int J Dent Clin 2011;3:75-6.  Back to cited text no. 10
    
11.
Ahmed HM, Al Rayes MH, Saini D. Management and prognosis of teeth with trauma induced crown fractures and large periapical cyst like lesions following apical surgery with and without retrograde filling. J Conserv Dent 2012;15:77-9.   Back to cited text no. 11
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12.
Danin J, Linder LE, Lundqvist G, Ohlsson L, Ramsköld LO, Strömberg T. Outcomes of periradicular surgery in cases with apical pathosis and untreated canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:227-32.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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