|Year : 2011 | Volume
| Issue : 2 | Page : 161-164
Multiple abnormalities in permanent maxillary incisors following trauma to the primary dentition
Nitesh Tewari1, Ramesh Kumar Pandey2
1 Department of Pedodontics and Preventive Dentistry, BBD College of Dental Sciences, Lucknow, Uttar Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, C.S.M. Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||9-Sep-2011|
3/82-83, Vrindavan Scheme-2, Raebareily Road, Lucknow 226 025, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Diverse consequences to the trauma to primary dentition are sometimes difficult to explain. This report describes a rare case of sequelae to primary tooth trauma. The traumatic episode which occurred at the age of 3 years resulted in abnormally large crowns of 11 and 21 with yellowish-brown discoloration and enamel hyperplasia. It also led to dilaceration in the root of 21 and enamel hypoplasia with discoloration in 12 and 22.
Keywords: Dilaceration, enamel hypoplasia, enamel hyperplasia, luxation, mesiodens
|How to cite this article:|
Tewari N, Pandey RK. Multiple abnormalities in permanent maxillary incisors following trauma to the primary dentition. J Indian Soc Pedod Prev Dent 2011;29:161-4
|How to cite this URL:|
Tewari N, Pandey RK. Multiple abnormalities in permanent maxillary incisors following trauma to the primary dentition. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2020 Feb 23];29:161-4. Available from: http://www.jisppd.com/text.asp?2011/29/2/161/84691
| Introduction|| |
The trauma to the primary dentition is almost a universal occurrence while growing up. Flores estimated the prevalence of primary tooth trauma to be 11-30%.  Andreasen and Ravn established its peak of incidence to be 2-4 years.  Luxation injuries especially intrusion and avulsion are the most common type of primary tooth trauma. ,,
The close proximity of roots of primary incisors, especially in the maxillary arch, makes the developing permanent tooth germs vulnerable to the injury after trauma to primary incisors.  Von Arx identified a prevalence rate of 23% for the developmental defects in permanent teeth following trauma to primary teeth. The highest prevalence was found after intrusive injuries. 
Andreasen et al. described the most common sequelae to primary tooth trauma as yellow or white enamel discoloration, white-yellowish brown discoloration of enamel with hypoplasia, crown dilaceration, odontoma-like malformation, root duplication, vestibular root angulation, lateral root angulation or dilacerations, partial or complete arrest of root formation, sequestration of entire tooth germ and ectopic, premature or delayed eruption or impaction. 
An unusual case of sequelae to primary tooth trauma comprising multiple abnormalities in the permanent maxillary central and lateral incisors has been presented here.
| Case Report|| |
A 13-year-old boy reported to the out-patient department with the chief complaint of pain in upper front teeth along with their malalignment. The medical history was noncontributory. The patient revealed a history of a severe traumatic episode at an age of 3 years. There were no records of the incident, though the parents affirmed that the patient had fallen into a well (about 30 feet deep) leading to avulsion of 51, 61 and intrusion of 52 and 62. There was no associated maxillary fracture or neurological abnormalities and the injury was managed without any further discomfort. Both 52 and 62 re-erupted, but had to be extracted later at 9 years of age.
It was further reported that 11 and 21 had erupted at 8 years while 12 and 22 at 10 years of age with no abnormality in eruption of 31, 32, 41, and 42. The patient stated that initially there was no pain associated with 11 and 21 though he later developed sensitivity to cold and sweets about 6 months ago.
Clinical examination revealed no extra-oral swelling. Intra-orally, the labial gingival margins in relation to 11 and 21 appeared inflamed. The maxillary central incisors were bulbous with larger mesiodistal diameter. While 11 showed patchy areas of yellowish-brown discoloration and white opacity, 21 had a uniform yellowish-brown discoloration. Crown of 21 also exhibited an increased clinical crown height with an anomalous "enamel hyperplasia" at the cervical third: from the disto-labial region to the middle of the labial surface. Rotation was seen in 11 along with cross bite [Figure 1].
|Figure 1: Crown abnormalities and discoloration in 11, 21, 12, and 22 with enamel hyperplasia in 21 and enamel hypoplasia in 12 and 22|
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The maxillary lateral incisors, with normal mesiodistal dimensions, had a marked constriction at the middle third of the labial surface. Crown of 12 had enamel hypoplasia with brown discoloration extending from middle third to the incisal edge. Enamel hypoplasia was less marked in 22, though yellowish-brown discoloration was present [Figure 1]. Both 11 and 21 were tender on percussion while 12 and 22 were normal. Pulp vitality tests proved 11 and 21 to be nonvital while 12 and 22 were vital.
Orthopantomograph revealed abnormal root morphology of 21: root dilacerations.  The anomalous crown morphology of 11, 21, 12, and 22 could also be appreciated [Figure 2]. An intraoral periapical radiograph exhibited that the root of 21 was dilacerated with an immature apex. The root of 11 also had an open apex. The abnormal radio-opacity in the crowns of 11, 21, 12, and 22 emphasized their anomalous mineralization. Another very interesting finding was the presence of an inverted mesiodens, in close proximity to middle and apical third of the root of 21. The shape of root of 21 seemed to follow the morphology of the supernumerary tooth [Figure 3].
|Figure 3: Intraoral periapical radiograph showing root dilacerations in 21 and an inverted mesiodens in close proximity to 21|
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After a thorough evaluation of the patient's clinical records, a treatment plan comprising root canal treatment of 11 and 21, extraction of the mesiodens, and later the prosthodontic rehabilitation of 11, 12, 21, and 22 were formulated. Apexification of 11 and 21 was carried out using the calcium hydroxide paste. After formation of an apical barrier, the root canals were obturated with guttapercha using lateral condensation.
Surgical extraction of the mesiodens was taken out after 3 weeks. After elevation of the flap, the hyperplastic enamel malformation could be very clearly seen in the cervical third of 21 and specks of enamel in the cervical third of 11. This anomalous enamel was smoothed using a sterile composite finishing but on a slow speed hand piece. The flap was sutured and the patient recalled after a week for removal of sutures [Figure 4]a-c.
|Figure 4: (a) Hyperplastic enamel malformation in cervical third of 21, specks of enamel in the cervical third of 11, and extraction socket of mesiodens. (b) Postoperative photograph after smoothing of the cervical enamel malformations in 11 and 21. (c) Extracted supernumerary tooth|
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After adequate gingival healing at the sixth week postoperative period, intermediate prosthodontic rehabilitation using an acrylic bridge was carried out [Figure 5]. A suggestion regarding the definitive porcelain crowns, to be carried out after 18 years of age, was also made.
|Figure 5: Intermediate prosthodontic rehabilitation using an acrylic bridge|
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| Discussion|| |
The severity of the damage to the permanent teeth depends upon the direction and intensity of impacting force, age of the child, stage of the development of permanent tooth germ, and the amount of dissipation of the impacting force. ,, The severe nature of trauma in the present case, leading to avulsion of 51 and 61 and intrusion of 52 and 62, and the age of impact (3 years) explains the clinical manifestation in 11, 12, 21, and 22 to some extent.
Formation of the permanent maxillary central incisor begins at 20 weeks in utero. Its enamel formation begins at 3-4 months of age and is completed by 4-5 years.  The impact of the trauma, though dissipated by the pliability of skeleton and avulsion of 51 and 61, might have resulted in disturbance in amelogenesis which was still not complete. This could have led to abnormal shape and discoloration of their crown. , The enamel hyperplasia in the cervical third of the labial surface is an unusual finding and can also be attributed to injured ameloblasts. The impact was severe enough to cause enamel hyperplasia and increased dimensions of 11 and 21 but did not progress to anodontoma-like malformation.
The hypoplastic constriction and discoloration in the middle third of 12 and 22 can be explained by direct injury to the enamel matrix by the intruding roots of 52 and 62. ,, Since the intruded tooth had erupted and the enamel matrix of the cervical third of 12 and 22 formed at a later age, it was spared. 
Dilaceration of the root of 11 and 21 can be attributed to the scar tissue formation as explained by Meyer, since root formation of permanent maxillary central incisors is not started before 4-5 years of age and the trauma in the present case which occurred at 3 years could not have caused a direct impact on the root angulation.  Another possible explanation can be the presence of an inverted mesiodens in close proximity to the root of 21. Although there is a high incidence of congenitally present supernumerary teeth in this region, a possibility of primary tooth trauma leading to partial division of the enamel organ and origin of the inverted mesiodens cannot be totally negated. ,
The treatment plan involving apexification using calcium hydroxide has been advocated by number of researchers.  The extraction of the impacted supernumerary tooth was carried out due to its proximity with the root of 21 and as it was a possible cause of the pain.  The decision for using the intermediate acrylic bridge was based on delaying the definitive rehabilitation till gingival margins have adequately established and pulp horns have receded in 12 and 22.
The rarity of this case can be emphasized by the simultaneous occurrence of enamel hyperplasia and hypoplasia in the same quadrant of the jaw, after the same traumatic episode. This clinical picture, especially the crown abnormalities in the permanent maxillary central incisors, is also difficult to classify according to the established criterion given by Andreasen et al. and Von Arx  for the sequelae to primary tooth trauma.
Such a case of multiple abnormalities in permanent teeth following trauma to the primary dentition emphasizes the need for creating awareness among the public and the healthcare professionals not only for the appropriate management of the immediate trauma but also for the long-term follow-up and subsequent management of its sequelae.
| References|| |
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|2.||Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1972;1:235-9. |
|3.||Von Arx T. Developmental disturbances of permanent teeth following trauma to the primary dentition. Aust Dent J 1993;38:1-10. |
|4.||Andreasen JO, Sundstro¨m B,Ravn JJ. The effect of traumatic injuries to the primary teeth on their permanent successors. I. A clinical and histological study of 117 injured permanent teeth. Scand J Dent Res 1971;79:219-83. |
|5.||Van der Linden F. Some general aspects of the normal development of the dentition. In: Development of the dentition. Chicago: Quintessence Publishing Co; 1983. p. 59-69. |
|6.||Turgut MD, Tekcicek M, Canogˇlu H. An unusual developmental disturbance of an unerupted permanent incisor due to trauma to its predecessor - a case report. Dent Traumatol 2006;22:283-6. |
|7.||Arenas M, Barberia E, Lucavechi T, Maroto M. Severe trauma in the primary dentition diagnosis and treatment of sequelae in permanent dentition. Dent Traumatol 2006;22:226-30. |
|8.||Rafter M. Apexification: A review. Dent Traumatol 2005;21:1-8. |
|9.||Russell KA, Folwarczna MA. Mesiodens--diagnosis and management of a common supernumerary tooth. J Can Dent Assoc 2003;69:362-6. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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