This paper describes the case of a 12-year-old male patient who presented a severe lateral luxation of the maxillary central incisors due to a bicycle fall. Treatment involved suture of the soft tissues lacerations, and repositioning and splinting of the injured teeth, followed by endodontic treatment and periodontal surgery. After a 2-year follow-up, clinical and radiographic evaluation revealed that the incisors presented satisfactory esthetic and functional demands.Este artigo apresenta o caso de um paciente de 12 anos de idade que apresentou uma luxação lateral severa dos incisivos centrais superiores decorrente de uma queda de bicicleta. O tratamento envolveu a sutura dos tecidos moles dilacerados e reposicionamento e fixação dos dentes traumatizados, seguidos por tratamento endodôntico e cirurgia periodontal. Após um acompanhamento de 2 anos, a avaliação clinica e radiográfica revelou que os incisivos apresentavam exigências estéticas e funcionais satisfatórias

DE ROSSI, Andiara

DE ROSSI, Moara

NELSON FILHO, Paulo

QUEIROZ, Alexandra Mussolino de

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Management of a complex dentoalveolar trauma: a case report

Biblioteca Digital da Produção Intelectual da Universidade de São Paulo (BDPI/USP)

Braz Dent J 20(3) 2009
Complex dentoalveolar trauma 259
INTRODUCTION
Traumatic injuries in young children and adoles-
cents are a common problem that usually results from 
accidents, contact sports, falls, and violence (1,2). In  the 
permanent dentition, the peak age of trauma incidence 
is between 8 and 10 years (3), and the most commonly 
affected teeth are the maxillary central incisors (1,4-7). 
Traumatisms in permanent dentition can appear rather 
severe, particularly when dental tissue injuries are as-
sociated with trauma to supporting tissues (8).
The most common types of injuries affecting 
periodontal tissues are luxations, whose prevalence 
varies from 15 to 61% (1). Luxation diagnosis depends 
on clinical and radiographic findings; laterally luxated 
teeth often have their crowns displaced palatally, which 
usually results in comminution or fracture of the labial 
alveolar bone and considerable injury to the periodontal 
ligaments (1). Although luxation can be clinically di-
agnosed, a radiographic examination must be done to 
ensure that it is the only injury (1,3). Because traumatic 
injuries are difficult to treat, the correct diagnosis must 
also be associated with prompt treatment and a long 
Management of a Complex DentoalveolarTrauma: 
A Case Report
Moara DE ROSSI1
Andiara DE ROSSI2
Alexandra Mussolino de QUEIROZ2
Paulo NELSON-FILHO2
1Department of Pediatric Dentistry, Piracicaba Dental School, State University of Campinas, Piracicaba, SP, Brazil
2Department of Pediatric Clinics, Preventive and Community Dentistry, Ribeirão Preto Dental School, 
University of São Paulo, Ribeirão Preto, SP, Brazil
This paper describes the case of a 12-year-old male patient who presented a severe lateral luxation of the maxillary central incisors 
due to a bicycle fall. Treatment involved suture of the soft tissues lacerations, and repositioning and splinting of the injured teeth, fol-
lowed by endodontic treatment and periodontal surgery. After a 2-year follow-up, clinical and radiographic evaluation revealed that 
the incisors presented satisfactory esthetic and functional demands.
Key Words: dentoalveolar trauma, lateral luxation, soft tissue, permanent tooth.
follow-up period so that the treatment is successful (1,9). 
This paper describes the treatment of a severe 
traumatic injury involving the extraoral soft tissues ex-
tending from the upper lip to the nose, as well as intraoral 
structures, namely the upper lip mucosa, the maxillary 
central incisors and the surrounding periodontal tissues 
in a 12-year-old boy followed up for a period of 2 years.
CASE REPORT
A 12-year-old Caucasian male patient was 
brought by his parents to the Emergency Unit of the 
Pediatric Dentistry Clinic of Ribeirão Preto Dental 
School, University of São Paulo (Brazil), about 10 h 
after a bicycle fall that resulted in dental trauma. The 
child had already been seen by the medical staff of the 
emergency unit of a local hospital, where suture of the 
extraoral tissues was done and no neurological damage or 
medical complications were detected. Past medical history 
was reviewed and a signed, written informed consent form 
was obtained from the parents for treatment and further 
publication of the case. The patient was in excellent health 
with no remarkable past medical history. 
Correspondence: Dra. Moara De Rossi, Departamento de Odontopediatria, Faculdade de Odontologia de Piracicaba, UNICAMP, Avenida Limeira 
901, 13414-903 Piracicaba, SP, Brasil. Tel: +55-19-2106-5200. Fax: +55-19-3421-0144. e-mail: moderossi@yahoo.com.br
ISSN 0103-6440Braz Dent J (2009) 20(3): 259-262
Braz Dent J 20(3) 2009 
260 M. De Rossi et al.
 Clinical examination showed nasal and maxillary 
lip bruises, as well as laceration of the maxillary labial mu-
cosa and buccal gingiva at the maxillary permanent central 
incisors, which had a lateral luxation and hypermobility. 
There was an alveolar bone wall fracture in this area and 
the roots were visible with no fractures. The right central 
incisor presented enamel cracking and fracture (Fig. 1). 
Periapical radiographic examination did not show root 
fracture or any other injuries involving other teeth. Lateral 
radiograph revealed fracture of the labial alveolar bone 
with the roots of the maxillary central incisors displaced 
buccally and the crowns displaced palatally.
The surgical treatment consisted of repositioning 
the teeth and bone fragments by finger pressure, with the 
patient under local anesthesia. A periapical radiograph 
was taken to ensure that the teeth had been correctly 
positioned in the socket. The teeth were splinted from 
canine to canine with composite resin and a 0.7 orth-
odontic wire, and the lacerated soft tissues were sutured 
(Fig. 2). Clinical treatment included antibiotic (Amoxil 
500 mg; GlaxoSmithKline, Rio de Janeiro, RJ, Brazil) 
and antiinflammatory (Cataflam 500 mg; Novartis, São 
Paulo, SP, Brazil) agents. The parents were informed about 
the importance of maintaining meticulous oral hygiene, 
regularly returning for clinical and radiographic follow up.
 After 15 days, both central incisors were treated 
endodontically and dressed with a calcium hydroxide-
based paste [Calen; S.S. White, Rio de Janeiro, RJ, Brazil; 
composition: 2.5 g CH, 0.5 g zinc oxide, 0.05 g colophony 
and 1.75 mL polyethylene glycol 400 (vehicle)]. The 
crown fracture of the right central incisor was restored 
with composite resin. After 30 days, the calcium hydroxide 
pasted was renewed, and the patient was asked to return 
for follow-up. However, the child failed to return to the 
Pediatric Dental Clinic for follow up, so the splinting was 
not removed and the root canals were not obturated.
Six months after the last follow-up visit, the 
patient returned to the Periodontic Dental Clinic, with 
loss of labial alveolar bone and gingival recession in 
the maxillary central incisors area (Fig. 3), where an 
acellular dermal matrix graft (Alloderm; Lifecell Cor-
poration, Branchburg, NJ, USA) was done for esthetic 
repair. However, the patient failed again to cope with 
treatment and came to the Pediatric Dental Clinic only 3 
months after the periodontal surgery, at which time the 
splint was removed and the root canals were obturated 
with gutta-percha and a calcium hydroxide-based sealer 
(Sealapex; Kerr Corporation, Orange, CA, USA) (Fig. 4). 
 The patient was recalled regularly. At 2 years 
follow-up, clinical and radiographic examination showed 
healthy tissues and teeth, and both incisors presented 
satisfactory functional and esthetic demands (Fig. 5). 
DISCUSSION
The 12-year-old boy of this case report had a 
complex traumatism involving dentoalveolar structures 
and soft tissues, caused by a bicycle accident. In fact, 
Figure 1. Initial clinical view following traumatic injury. A= Sutured extraoral soft tissue extending from the upper lip to the nose is 
shown. B= Both maxillary central incisors and the alveolar bone are displaced, and the right central incisor has a crack on the enamel.
Braz Dent J 20(3) 2009
Complex dentoalveolar trauma 261
male traumatic injuries to permanent dentition appear 
to be more severe and are among the variety of condi-
tions that can cause trauma. Indeed, accidents involving 
bicycles or other sports activities account for 30% of 
the injuries to the facial region (2).
The time interval elapsed since injury is very 
important because it influences the choice of treatment 
(1,4). According to Andreasen et al. (1), repositioning 
of the dislocated teeth is more difficult after 48 h of the 
injury. In the present case, the repositioning was per-
formed around 10 h after the injury, so treatment was 
possible and led to satisfactory results.
Pulp necrosis is an important consequence of 
luxation injuries and its development depends on the 
type of injury and the stage of root maturation. It is most 
frequent in mature teeth compared to teeth with open 
apices (10). Studies have shown that if loss of vitality 
or root resorption is present, the pulp must be removed 
and a dressing of non-setting calcium hydroxide must 
be placed in the canal, to prevent toxins of the necrotic 
pulp from triggering an inflammatory resorption (11,12). 
In the present report, an endodontic treatment including 
dressing of the root canal with a calcium hydroxide-
based paste was performed, which is usually necessary 
in the case of teeth with mature apices undergoing large 
Figure 2. Clinical view showing the repositioned teeth with light-
curing resin and orthodontic wire as well as sutured gingival tissue.
Figure 3. Clinical view 6 months after the injury. The splints are 
still present. Loss of buccal alveolar bone and gingival recession 
in both maxillary central incisors.
Figure 4. Periapical radiograph taken after root canal treatment. 
Figure 5. Clinical view 2 years after the injury. The right central 
incisor was restored with composite resin. The appearance, 
gingival contour, and function were normal.
Braz Dent J 20(3) 2009 
262 M. De Rossi et al.
luxations (13).
After lateral luxation, immediate reposition 
and stabilization of the teeth in their anatomically cor-
rect positions are essential to optimize healing of the 
periodontal ligament and neurovascular supply, while 
maintaining esthetic and functional integrity (14). The 
splinting period indicated for periodontal ligament 
therapy is 2-4 weeks, but in cases of lack of periodontal 
support or breakdown of marginal bone, as in the pres-
ent situation, the ideal splinting time must be extended 
to 8 weeks (4,15). In the present case, removal of the 
splint occurred only after 9 months because the patient 
failed to cope with the treatment plan. Splinting with 
orthodontic wire and composite resin for stabilization 
of traumatically displaced teeth, as performed in the 
present case, has been reported to lead to satisfactory 
results (16), since it allows for physiologic mobility 
and easy cleansing. These features may have prevented 
complications like dental ankilosis and dental biofilm 
accumulation, despite the prolonged splinting period. 
The meticulous oral hygiene maintained by the patient 
was also important to prevent any periodontal inflam-
mation that might have been harmful to the treatment.
The loss of marginal bone support is common in 
cases of alveolar bone wall fracture (1), the use of an acel-
lular dermal matrix has been considered as one of the best 
treatments for root coverage, reduction of recession, and 
gain of clinical attachment (17,18). In the present case, 
the labial alveolar bone was lost and a periodontal surgery 
with Alloderm resulted in a greater formation of keratinous 
tissue and an esthetically acceptable gingival contour. 
It is impossible to completely prevent accidents 
that might result in dental injuries (2), but their associ-
ated complications can be avoidd by ready and adequate 
treatment and follow-up. In the present case, although 
the patient missed the follow up for about 6 months, the 
correct diagnosis and treatment were crucial to the suc-
cessful management and preservation of the traumatized 
teeth. Finally, it should be highlighted the importance of 
a multidisciplinary treatment of traumatic injuries, such 
as in the present case, in which endodontic, restorative 
and periodontal procedures were combined to recover 
the esthetics and function of the traumatized area.
RESUMO
Este artigo apresenta o caso de um paciente de 12 anos de idade 
que apresentou uma luxação lateral severa dos incisivos centrais 
superiores decorrente de uma queda de bicicleta. O tratamento 
envolveu a sutura dos tecidos moles dilacerados e reposiciona-
mento e fixação dos dentes traumatizados, seguidos por tratamento 
endodôntico e cirurgia periodontal. Após um acompanhamento de 
2 anos, a avaliação clinica e radiográfica revelou que os incisivos 
apresentavam exigências estéticas e funcionais satisfatórias.
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Accepted August 11, 2009


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Management of a complex dentoalveolar trauma: a case report

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