Year : 2008 | Volume
: 26 | Issue : 7 | Page : 121--124
Esthetic and endosurgical management of turner's hypoplasia; a sequlae of trauma to developing tooth germ
BA Bhushan, S Garg, D Sharma, M Jain
Department of Pedodontics and Preventive Dentistry, M.M. College of Dental Sciences and Research, M.M University Mullana, Ambala, Haryana, India
D/o Mr. Deepak Jain, Kailash View, Buria., District Yamunanagar, Haryana
Turner«SQ»s hypoplasia usually manifests as a portion of missing or diminished enamel, generally affecting one or more permanent teeth in the oral cavity. A case report of 8 year old girl who met with trauma at 2 years of age leading to primary incisors being knocked out, reported after 6 years with complaint of pain and discharge in her anterior malformed teeth is discussed in this article. The permanent incisors erupted with dilacerated crown, root malformations and missing enamel. Further, patient developed sinus, lateral root pathology, tooth mobility and malocclusion in relation to affected teeth which were managed by esthetic, functional, endodontic and surgical procedure. Root canal treatment along with palatal contouring and esthetic restoration by light cure composite was performed on the tooth with crown dilaceration and sinus, where as surgical management was considered for the tooth with root malformation.
|How to cite this article:|
Bhushan B A, Garg S, Sharma D, Jain M. Esthetic and endosurgical management of turner's hypoplasia; a sequlae of trauma to developing tooth germ.J Indian Soc Pedod Prev Dent 2008;26:121-124
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Bhushan B A, Garg S, Sharma D, Jain M. Esthetic and endosurgical management of turner's hypoplasia; a sequlae of trauma to developing tooth germ. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2013 May 24 ];26:121-124
Available from: http://www.jisppd.com/text.asp?2008/26/7/121/44838
Turner's hypoplasia usually manifests as a portion of missing or diminished enamel, generally affecting one or more permanent teeth in the oral cavity. If involve anterior teeth, most likely cause is traumatic injuries leading to primary incisors being knocked out or driven into the alveolus affecting the permanent tooth bud. The affect of trauma are more pronounced if it occurs prior to third year of life. The topographic relationship of the primary teeth to the permanent tooth germ explains the potential for possible developmental disturbances.  The developmental defects of the permanent successor tooth range from mild alteration in enamel mineralization in form of simple white or yellow brown discoloration to crown dilaceration, crown duplication, root dilaceration, root duplication, odontome like malformation, partial or complete arrest of root formation to severe sequestration of the developing tooth germ. ,
An 8 year old female patient reported to the Department of Pedodontics and Preventive Dentistry with chief complaint of spontaneous but intermittent pain in malformed upper front teeth for last one month. Patient gave history of loss of primary incisors due to trauma at the age of 2 years. Clinical examination showed the presence of moderate to severe yellowish brown discoloration with hypoplastic enamel of anterior teeth. Periapical sinus was present between two permanent maxillary central incisors and left maxillary central and lateral incisor [Figure 1],[Figure 2]. Lateral incisor exhibited grade II mobility with vitality test for both right incisors being negative. Crown dilaceration had led to cross bite in relation to right lateral and left central incisors with its palatal displacement giving a hook like appearance [Figure 1]. Radiographic examination revealed a bend in middle third of the crown of left lateral and right central incisor which were foreshortened coronally. Periapical radiolucency in relation to left central incisor and lateral radiolucency extending from gingival third to mid portion of root on the mesial aspect along with a lateral root defect and calcification in its apical third was observed in relation to left lateral incisor [Figure 3].
Initially to motivate the patient esthetic treatment with palatal contouring and light cure composite restoration was performed on left central and lateral incisor following root canal treatment. Cross bite was managed by palatal contouring and esthetic restoration following which the surgical treatment of non healing sinus between right central and lateral incisors was planned [Figure 4]. Radiograph taken with gutta percha in the sinus indicated to the radiolucency present on the mesial aspect of lateral incisor [Figure 5]. Full thickness flap raised exposing the surgical site revealed a bony defect of around 4mm with granulomatous lesion [Figure 6]. Total excisional biopsy of the lesion was performed and submitted for histological examination. After careful curettage the exposed root defect on the mesial aspect of lateral incisor was contoured with glass ionomer cement [Figure 7]. The histopathological examination showed presence of acute inflammatory cells suggestive of granulation tissue [Figure 8]. Recall visit after six days following surgery, healing was appreciated with no clinical signs and symptoms. Clinical and radiographic examination after 3 months showed decreased mobility, bone deposition and healing of the lateral radiolucency [Figure 9]. Complete signs of healing with no evidence of any pathology was observed even at six month recall [Figure 10].
In the present case report it was seen that traumatic injuries to primary predecessors had lead to developmental disturbances in their successor. The permanent tooth which erupted exhibited crown and root defects like defective enamel formation and dilacerations. Tiecke et al , has defined crown dilaceration as a deviation or bend in the linear relationship of a crown to its root.  Permanent maxillary central incisors are the most commonly dilacerated teeth. Andreasen reported dilaceration incidence to be 25% in permanent teeth with developmental disturbances secondary to primary tooth injury.  Van Gool emphasized that dilaceration of permanent tooth followed a traumatic injury to deciduous predecessor where the tooth was driven into the alveolus. , Stewart investigated 41 cases of dilacerated incisors and found that trauma accounted for only 22%.  The pathology of crown dilaceration can be explained by the theory of displacement of the enamel epithelium and mineralized portion of tooth in relation to dental papilla and cervical loop. Traumatic non axial displacement occurs in already formed hard tissue portion of the tooth. , Randy Q. states that the clinical appearance of the permanent incisors with dilaceration of crown will depend on the stage at which the injury to the developing tooth bud occurred. Injury in second or third year of life may lead to only a portion of the crown tipping while whole of the crown may be tipped if the injury occurred during the fourth or fifth year. The calcified coronal portion moves bodily within the bone in response to an injury, leaving behind the more apically situated soft tissue elements undergoing calcification. If the formative tissue manages to survive the incident, it will continue development in its original alignment so that a deviation results between it and the previously calcified part of the tooth that has been moved by the injury.  In the present case the crown dilaceration was managed by palatal contouring and rehabilitation by tooth colored light cure composite which aided in both the orthodontic and esthetic management.
Brownish discoloration occurs due to disturbances in ameloblastic layer leading to defective matrix formation caused by traumatic injuries but the stretched inner enamel epithelium continues to induce the differentiation of new odontoblast and hence the dentine formation is not affected. Consequently a horizontal band of dentine without enamel on the facial aspect is evident whereas the displaced inner enamel epithelium and ameloblast form a cone of hard tissue on the lingual aspect usually projecting into the pulp canal. The intact lingual cervical loop forms an enamel covered cusp. 
In the present case even though the tooth was unaffected by carious lesion periapical and lateral pathologies were observed which best explains the presence of a crown bend along with defective enamel and open dentinal tubules acting as a nidus for bacterial entry into the pulp space thereby leading to pulpal necrosis. The endodontic treatment was followed by surgical intervention for the treatment of non healing sinus of the affected tooth. So it can be concluded that the presence of crown dilaceration and hypoplastic enamel led to complications like formation of radiolucencies whose treatment was not possible through routine approach. It was possible to save the tooth with severe turner's hypoplasia with minimum possible surgical intervention and at six month recall visit the patient was asymptomatic, had improved esthetics and more stable psychologically.
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