Developmental disturbances in permanent successors after intrusion injuries to maxillary primary incisors

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1 Developmental disturbances in permanent successors after intrusion injuries to maxillary primary incisors M. L. ODERSJÖ*-**, G. KOCH** SUMMARY. Aim The aim of the present study was to report the frequency of developmental disturbances in permanent teeth as a result of intrusive injuries to the primary predecessors and relate this to the degree of intrusion, the age of the child, the developmental stage of permanent germ and the treatment given. Methods Seventy children with previous intrusive trauma of their maxillary primary incisors were recalled for a follow-up examination of the erupted permanent successors. The children had a total of 118 intruded teeth. The severity of intrusion was recorded as well as the developmental stage of the permanent successor and the treatment given at the time of trauma. The permanent successors were examined for different levels of developmental disturbances. Results Seventy per cent of the succeeding incisors had some complications in development. White or yellow-brown hypomineralisation was the most common finding representing 60% of all complications. The more serious complications such as circular hypoplasia, crown dilaceration, odontoma-like malformation, root developmental disturbances, sequestration of the tooth germ, and eruption disturbances were few and the majority (90%) related to trauma before the age of 3 years combined with severe intrusion. When the intruded primary incisor was extracted, 80% of the permanent successors developed complications. Conclusions Traumatic injuries to primary incisors are common. Because of the close relationship between the apices of the primary incisors and developing permanent teeth, disturbances in development occur. Intrusion of a primary incisor often occurs before the age of 3 years and the risks of damage occurring to the permanent germ are high. KEY WORDS: Trauma, Intrusion, Primary teeth, Sequelae Introduction Epidemiologic studies indicate that about 30% of all children traumatize one or more of their primary incisors [Andreasen and Ravn, 1972; Andreasen, 1985, 1994]. Intrusive luxation injuries to primary incisors are a common trauma, especially in children up to the age of 3 years [Ravn, 1968; Selliseth, 1970; Andreasen and Ravn, 1972; Haavikko and Rantanen, 1976; Borum, 1994]. Developmental disturbances of permanent successors are often seen as a result of the intrusion of primary incisors [Andreasen and Ravn, 1971; Ravn, 1976; Brin et al., 1984; Ben-Bassat et al., 1985; von Arx, 1993, *Department of Pedodontics, Faculty of Odontology, Göteborg University and Public Dental Service, Göteborg, Sweden **Department of Paediatric Dentistry, The Institute for Postgraduate Dental Education, Jönköping, Sweden 1995, Diab and El Badrawy, 2000]. The close relationship between the apices of the primary teeth and the developing permanent successors explains the high prevalence of disturbances. There are a number of reports on different luxation injuries to primary teeth and their effect on the permanent successor. However, most of the materials presented are small, and the frequency of disturbances in permanent teeth differs considerably. This is particularly true concerning intrusive luxation injuries to primary teeth. The reasons for this might be that the material in studies on intrusion varies in respect of clinical examination at the time of trauma, e.g. registration of degree of intrusion, age of the child, developmental stage of the permanent tooth germ, and treatment. The aim of the present study was therefore to report the frequency of developmental disturbances in permanent teeth as a result of EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/

2 M. L. ODERSJÖ, G. KOCH intrusive injuries to the primary predecessors and relate this to the degree of intrusion, the age of the child, the developmental stage of permanent tooth germ and the treatment given. Knowledge of factors influencing the frequency and severity of complications are important in the prediction of disturbances resulting from trauma. Materials and methods In this study were included all children who had been referred to the Department of Paediatric Dentistry, The Institute for Postgraduate Dental Education, Jönköping, Sweden (IPGDE), because of trauma resulting in the intrusion of a primary incisor were at least 8 years old at the time of the study, and had fully erupted permanent maxillary central incisors. With one exception, children who had undergone more than one traumatic incident were excluded. The study population, therefore, consisted of 95 children who had experienced a traumatic intrusion of a primary incisor between 1973 and Most of the trauma had happened by falling against the ground or furniture while playing. Only few trauma were caused by traffic accidents. The children had been given emergency treatment at IPGDE and the more detailed treatment was pending. Improved oral hygiene and abandonment of the use of pacifiers was advised. Antibiotics were seldom prescribed. Radiographs were available from the time of the trauma for all the children. They all had been followed up, clinically and radiographically, for several years depending on healing and treatment. All 95 children were called for a follow-up examination of any sequelae in the permanent successors because of the intrusive trauma of their primary incisors. Fifteen of the children had moved from the area and 10 declined to participate. Thus 70 children (29 girls and 41 boys) with a total of 118 intruded teeth (38 had one intruded tooth, 23 had two teeth, 2 had three teeth, and 7 had four teeth) were examined by one of the authors (MLO) concerning their permanent incisors (Table 1). One boy who had been exposed to intrusive trauma on two occasions but which involved different teeth was included. The followup included both a clinical and a photographic examination. Prior to this clinical examination, all recent radiographs of the maxillary incisor region were requested from the Public Dental Service that was now caring for each child. At the followup examination and from previous dental records, the following information [modified from Andreasen and Ravn 1971; von Arx 1995] was collected. - Sex. - Age at the time of trauma (registered at 1-year intervals, e.g. in the tables, 2-3 years means that the child had reached the age of 2 years but not yet turned 3). - The tooth or teeth that were traumatized. - The developmental stage of the permanent successor at the time of trauma as: mineralization of the incisal part; mineralization of about half of the crown; mineralization of the entire crown. - The degree of intrusion of the primary incisors at the time of trauma: less than half of the crown was intruded; half or more of the crown was intruded; all of the crown was intruded (complete). - Treatment given to the intruded incisor at the time of trauma and later: - no extraction re-eruption without complications, re-eruption with mild complications (obliteration or colour changes with no radiographically verified signs of periapical infection); - extraction of the intruded incisor immediately (within 1 week), later because of complications (pulp necrosis with radiographically verified signs of periapical infection, long-lasting mobility in combination with periapical infection, anchylosis, or fistula). - Complications in the erupted permanent successor (a tooth can show more than one complication): white or yellow-brown enamel hypomineralisation; localised enamel hypoplasia; hypomineralisation and circular enamel hypoplasia; crown dilaceration; odontoma-like malformation; disturbed root development; sequestered tooth germ; disturbed eruption; no changes. These different outcomes are illustrated in figures EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2001

PRIMARY TEETH INTRUSION a a FIG. 1 -Boy 2.

Observe the close contact with the apex of

3 PRIMARY TEETH INTRUSION a a FIG. 1 -Boy 2.5 years at the time of trauma. a: half of the crown 61 intruded. b: white enamel hypomineralisation. FIG. 2 - Boy 2.5 years at the time of trauma. a: complete intrusion 61. Half of the crown 21 mineralised. Observe the close contact with the apex of 61 and 22. b: white enamel hypomineralization and localised enamel hypoplasia 21, 22. b b a b c FIG.3 - Girl 1.7 years at the time of trauma. a: complete intrusion 61. Half of the crown 21 mineralised. b and c: radiograph and clinical picture of hypomineralisation and circular enamel hypoplasia. a b c FIG.4 -Girl 1.7 years at the time of trauma. Complete intrusion. a: radiograph at 3.7 years of age. No re-eruption. Later extraction. b and c: radiograph and clinical picture of hypomineralisation and crown dilaceration 21. EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/

M. L. ODERSJÖ, G. KOCH a b c FIG.5 - Girl 9 months at the time of trauma. All primary maxillary incisors intruded to half of the crown. a: radiograph 3 months after trauma.

Note odontoma-like malformation of crown 11, tendency to pre-eruption and early root formation. c: radiograph at 7.5 years of age. Note the rapid development of the root 11.

Among the 118 traumatized primary maxillary incisors, the tooth that was most frequently intruded was the central incisor.

4 M. L. ODERSJÖ, G. KOCH a b c FIG.5 - Girl 9 months at the time of trauma. All primary maxillary incisors intruded to half of the crown. a: radiograph 3 months after trauma. 51 inflammatory apical resorption and tooth germ 11 incisal part mineralised and malformed. b: radiograph at 5 years of age. Note odontoma-like malformation of crown 11, tendency to pre-eruption and early root formation. c: radiograph at 7.5 years of age. Note the rapid development of the root 11. Results More than 85% of the intrusive accidents occurred before the age of 3 years (Table 1). Among the 118 traumatized primary maxillary incisors, the tooth that was most frequently intruded was the central incisor. The distribution between left and right central incisors was equal, 46 of each. It was possible to register the developmental stage of the permanent successor at the time of Child s age* N. intruded teeth N. childr. at trauma (%) (%) (11) 5 (7) (33) 28 (39)** (45) 29 (41) (6) 6 (9) (4) 2 (3)** (1) 1 (1) ** * Registered at 1-year intervals e.g. 2-3 years means that the child has reached the age of 2 years but not yet turned 3 ** Intrusive trauma had occurred to one child on two separate occasions and affected different teeth TABLE 1 - Intruded primary incisors distributed according to age at the time of trauma. trauma in 79 teeth as: incisal part mineralised 11 (14%); mineralisation of half of the crown 48 (61%) and mineralisation of the entire crown 20 (25%). For the rest of the permanent successor teeth, the radiographs gave no clear-cut information. At the time of trauma, 75% of the permanent successors had not reached the developmental stage where the entire crown was mineralised. Nine teeth had been extracted within one week, and 109 had been left for re-eruption. Thirty-four teeth had to be extracted later because of complications such as pulp necrosis, resorption, and absence of re-eruption. Thus the success rate for the 109 teeth left for re-eruption was 69%. The distribution according to treatment of 118 teeth was divided into the no extraction group, of which 65 (55%) erupted without complications and 10 (8%) erupted with mild complications, and the extraction group, where 9 (8%) were extracted immediately (within one week) and 34 (29%) needed a later extraction. About 70% of all permanent successor teeth in children with intruded primary incisors developed complications (Table 2). The most commonly found disturbance was white or yellow-brown enamel hypomineralisation, which represented 59% of all disturbances, followed by localised hypoplasia (27%). The other changes were few. The seven teeth with the most serious complications were found in four children who had intrusion of half the crown or more and whose mean age at the time of trauma was 1.5 years. 168 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2001

5 PRIMARY TEETH INTRUSION Complications Age in years at the time of trauma Total compl (%) White or yellow-brown enamel hypomin (59) Localized enamel hypoplasia (27) Hypomin. + circular enamel hypoplasia (17) Crown dilaceration (4) Odontoma-like malformation (1) Disturbed root development (1) Sequestered tooth germ (0) Disturbed eruption (2) Number and percentage (in brackets) of teeth with complications 9 (69) 28 (72) 37 (70) 3 (43) 5 (100) 1 (100) 83 (70) TABLE 2 - Complications in permanent successors distributed according to age at the time of trauma (a tooth can show several complications). Complications Degree of intrusion Developmental stage-mineralized <1/2 crown 1/2 or more Complete Incisal part 1/2 crown Entire crown White or yellow-brown enamel hypomin Localized enamel hypoplasia Hypomin. + circular enamel hypoplasia Crown dilaceration Odontoma-like malformation Disturbed root development Sequestered tooth germ Disturbed eruption Number and percentage (in brackets) of teeth with complications 37 (79) 18 (62) 28 (67) 9 (82) 33 (69) 15 (75) TABLE 3 - Complications in permanent successors distributed according to the degree of intrusion of the primary incisor and the developmental stage of the permanent tooth at the time of trauma. Eleven (16%) intruded primary central incisors were the source not only of a complication on a permanent central incisor but also a developmental disturbance on a permanent lateral incisor. The distribution of complications in permanent successors is presented in Tables 2-5. It was found that the same tooth could have more than one complication. Thus one tooth had three complications and seven teeth had two complications each. Most were hypomineralisations or localised hypoplasias, while severe disturbances such as crown dilaceration and odontoma-like malformations were few (Table 2). About 60% of the primary teeth showed a degree of intrusion of more than half the crown and 35% had crowns that were completely intruded. The effect of the degree of intrusion of the primary tooth on complications in the permanent successors is presented in Table 3. When less than half the crown of the primary incisor was intruded, approximately 80% of the successor teeth developed complications. When the primary incisor was completely intruded, approximately 70% of the successor teeth developed complications. The most serious, such as crown dilaceration, odontoma-like malformations, and root developmental disturbances, were found only when EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/

6 M. L. ODERSJÖ, G. KOCH half or more of the crown was intruded (Table 3). Irrespective of the developmental stage of the permanent tooth at the time of trauma, about 75% of the teeth had complications. The more serious complications were found when the trauma had occurred before the entire crown of the permanent successor was mineralised (Table 3). In 19 of the 21 teeth that had severe complications (hypomineralization and circular enamel hypoplasia or worse), intrusion was half or more of the crown and had occurred when the child was under the age of 3 years (Table 2, 4). In Table 5 it can be seen that a higher percentage of permanent successors had complications in those children where the intruded incisor had been extracted immediately or later. About 80% of the extraction cases developed complications in the permanent successor compared with about 65% in the no extraction group. Almost all the serious complications were found in the late extraction group. Discussion The present study is retrospective, descriptive in nature. The rather small subgroups within the material did not allow us to perform meaningful statistical analysis on differences between the groups. When analysing the results it must also be remembered that the patients in the present study Complications Age at trauma (yrs) Total complications White or yellow-brown enamel hypomin Localized enamel hypoplasia Hypomin. + circular enamel hypoplasia Crown dilaceration Odontoma-like malformation Disturbed root development Sequestered tooth germ Disturbed eruption No changes TABLE 4 - Complications in permanent successors according to intrusion of half or more of the primary tooth crown and age below 3 years at the time of trauma. Complications in permanent teeth No extraction Extraction RE-ERUPTION Immediately Later no complications mild complications (within a week) White or yellow-brown enamel hypomin Localized enamel hypoplasia Hypomin. + circular enamel hypoplasia Crown dilaceration Odontoma-like malformation Disturbed root development Sequestered tooth germ Disturbed eruption Number and percentage (in brackets) of teeth with complications 42 (65) 6 (60) 7 (78) 28 (82) TABLE 5 - Complications in permanent successors distributed according to treatment and follow-up of primary incisor. 170 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2001

7 PRIMARY TEETH INTRUSION had been referred to a specialist clinic in paediatric dentistry. Our study might therefore represent more severe intrusions and younger patients compared with those from general dental practice. The frequency of complications could therefore be expected to be somewhat higher than in a less selected material. An analysis of the dropouts at the time of trauma revealed a distribution of age and degree of intrusion equal to those in the material studied. They could thus not have influenced the outcome of the present study. The high frequency of complications in permanent successor teeth in the present study is in accordance with findings presented by Andreasen and Ravn [1971] and Selliseth [1970]. In other studies [Ravn, 1976; Brin et al., 1984; von Arx, 1995], a somewhat lower frequency of complications caused by the intrusion of primary incisors, between 45% and 60%, has been reported. Possible explanations for this might be differences in the criteria used to diagnose the complications, the age distribution of the children at the time of trauma, and the severity of the trauma. The ratio of boys to girls in this study was 1.4:1, which is similar to the ratios presented by other authors [Andreasen and Ravn, 1971; Selliseth, 1970]. Compared with Ravn [1976], who found complications in 54% of the intruded teeth and intrusion of more than one tooth in 24% of the children, we found 70% and 45% respectively in the present study. The present study also included a higher percentage of children under the age of 1 year. This study thus has both cases that had undergone more severe trauma and younger individuals, which might explain the difference in frequency of complications. It is important to observe that in the present study, as in other similar ones [Andreasen and Ravn, 1971; von Arx, 1995; Ben-Bassat et al., 1989; Brin et al., 1984], the most frequent complications were mild, for example white or yellow-brown enamel hypomineralisations. These accounted for more than 50% of cases. Severe disturbances such as hypomineralisation and circular enamel hypoplasia, crown dilaceration, and odontoma-like malformations seem to occur only when the child is under 3 years of age at the time of trauma and when at least half or more of the primary crown is intruded. Severe complications might be expected in 90% of such cases.this is also in line with results presented by Ravn [1976], Ben-Bassat [1985], Zilberman et al. [1986], and von Arx [1995] who stressed that if the intrusion is severe and if the successor is in an early developmental stage, the risk of complications is higher. Complications to the permanent lateral incisors (16%) after intrusion of the primary central incisor were high and unexpected. However, this had been observed by von Arx [1995] and a thorough analysis of the radiographs of the present study revealed that the intruded root apex was often very close to the location of the hypoplasia after the permanent lateral incisor had erupted (Fig. 2). The influence of treatment of the intruded primary incisors on complications in permanent successors has been discussed by several authors [Selliseth, 1970; Andreasen and Ravn, 1971; Ravn, 1976; von Arx, 1995]. The frequency of complications in the permanent successors was more pronounced if the primary incisors had been extracted (about 80%) compared with the nonextraction cases (about 60%). These findings are in agreement with von Arx [1995] and supported by Ravn [1976] but differ slightly from Selliseth [1970]. It might be expected that the extraction cases represented more severe trauma and that a combination of infection and pulp necrosis might increase the risk of complications. However, there seems to be no clear rationale to extract intruded primary incisors immediately. Retrospective studies on traumatic injuries to the teeth covering periods of several years have a natural built-in weakness. In the future, therefore, it is important that studies focus on evaluating the effects of trauma in a prospective way. Such a study is in process and it will also cover the epidemiology of trauma to the primary teeth in a non-selected child population. References Andreasen JO, Ravn JJ. The effect of traumatic injuries to primary teeth on their permanent successors. II. A clinical and radiographic follow-up study of 213 teeth. Scand J Dent Res 1971; 79: Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972; 1: Andreasen JO. Challenges in clinical dental traumatology. Endodont Dent Traumatol 1985; 1: Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3rd Ed. Copenhagen: Munksgaard; EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/

8 M. L. ODERSJÖ, G. KOCH Ben Bassat Y, Brin I, Fuks A, Zilberman Y. Effect of trauma to the primary incisors on permanent successors in different developmental stages. Pediatr Dent 1985; 7: Ben-Bassat Y, Brin I, Zilberman Y. Effects of trauma to the primary incisors on their permanent successors: multidisciplinary treatment. J Dent Child 1989; 56: Brin I, Fuks A, Ben-Bassat Y, Zilberman Y. Trauma to the primary incisors and its effects on the permanent successors. Pediatr Dent 1984; 6: Borum MK. Traumatic injuries to primary teeth; complications in the primary and young permanent dentition (in Danish) Thesis: Copenhagen University; Diab M, El Badrawy HE. Intrusion injuries of primary incisors. Part III: Effects on the permanent successors. Quintessence Int 2000; 31: Haavikko K, Rantanen L. A follow-up study of injuries to permanent and primary teeth in children. Proc Finn Dent 1976; 72: Ravn JJ. Sequelae of acute mechanical traumata in the primary dentition. A clinical study. ASDC J Dent Child 1968; 35: Ravn JJ. Developmental disturbances in permanent teeth after intrusion of their primary predecessors. Scand J Dent Res 1976; 84: Selliseth NE. The significance of traumatised primary incisors on the development and eruption of permanent teeth. Eur Orthod Soc Trans 1970; 46: von Arx T. Developmental disturbances of permanent teeth following trauma to the primary dentition. Aust Dent J 1993; 38: von Arx T. Intrusion of primary teeth and its effects on the development of permanent successors (in German). Schweiz Monatsschr Zahnmed 1995; 105: Zilberman Y, Fuks A, Ben Bassat Y, Brin I, Lustmann J. Effect of trauma to primary incisors on root development of their permanent successors. Pediatr Dent 1986; 8: EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 4/2001

Rama Univ J Dent Sci 2017 June;4(2): Orthodontic treatment for ectopically erupted tooth

Rama Univ J Dent Sci 2017 June;4(2): Orthodontic treatment for ectopically erupted tooth Case Report Early Orthodontic Treatment of Unusual Trauma Caused by Ectopically Erupted Maxillary Central Incisor Verma VK, Ashok P, Sachan A, Badhauria V Abstract: Ectopic eruption or impaction of permanent