J Clin Exp Dent. 2018;10(7):e709-12.

Sequelae of trauma in primary dentition

Journal section: Operative Dentistry and Endodontics doi:10.4317/jced.54856

Publication Types: Case Report http://dx.doi.org/10.4317/jced.54856

Fusion of permanent teeth as post-traumatic sequelae of trauma in primary

dentition: A case report with fifteen years of follow-up

Vanessa Costa 1, Ivam da Silva-Júnior 2, Ayah Shqair 2, Andressa Gastmann 2, Elaine Baldissera 1, Marília
Goettems 1,2, Dione Torriani (in memorian) 1, Rudimar-Antonio Baldissera 1, Thiago-Marchi Martins 1

1
PhD, School of Dentistry, Federal University of Pelotas, Pelotas-RS, Brazil
2
MsC, Post Graduate Program in Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas-RS, Brazil

Correspondence:
Department of Social and Preventive Dentistry
Federal University of Pelotas
Rua Gonçalves Chaves, 457
Centro, Pelotas, RS, Brasil
Costa V, da Silva-Júnior I, Shqair A, Gastmann A, Baldissera E, Goettems
polinatur@yahoo.com.br
M, Torriani D, Baldissera RA, Martins TM. Fusion of permanent teeth as
post-traumatic sequelae of trauma in primary dentition: A case report with
fifteen years of follow-up. J Clin Exp Dent. 2018;10(7):e709-12.
Received: 24/03/2018
http://www.medicinaoral.com/odo/volumenes/v10i7/jcedv10i7p709.pdf
Accepted: 26/04/2018

Article Number: 54856 http://www.medicinaoral.com/odo/indice.htm

© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: jced@jced.es
Indexed in:
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DOI® System

Abstract
Traumatic dental injuries in primary dentition present risk of sequelae in the permanent dentition. In this case
report, we describe the management and long term follow-up of sequelae affecting permanent central incisor due
to prior intrusive luxation and subluxation of the corresponding primary tooth. A 5-year-boy was referred for treat-
ment, with history of fall by the age of 21 months, which caused subluxation of the primary maxillary right and left
central incisors, and intrusion of the maxillary right lateral incisor. Radiographic and clinical monitoring was regu-
larly performed. Hypoplasia and crown dilaceration of the permanent maxillary right central incisor was detected,
as well as an enamel bridge between the central and lateral right incisors was diagnosed by cone bean tomography.
Gingevectomy followed by the breaking of the enamel junction between the crowns of lateral and central incisors
and indirect facet in composite resin were used to treat the sequelae. A precise diagnosis, involving a multidiscipli-
nary team, contributed to the success of treatment.

Key words: Case reports, follow-up studies, pediatric dentistry, tooth, deciduos, complications.

Introduction affect the crown, root or the entire bud of the perma-
Traumatic dental injuries (TDI) in primary dentition nent successor. Clinically, alterations may occur such as
present risk of sequelae in the permanent dentition, due hypoplasia of the enamel, dilaceration of the crown, and
to the close relationship between the apices of primary discoloration (1). On the other hand, other complica-
teeth and the developing permanent successor buds (1). tions affecting the root region may be detected include:
In the permanent teeth, the prevalence of developmen- duplication and partial or total dilaceration. Other seque-
tal disturbance following injuries to their predecessors lae include alterations in the eruption process may be
varied from 12 to 74% (2). Usually, these sequelae can identified during the follow up process (3).

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Intrusive luxation is the type of TDI most likely to cau- llow-up assessment, the absence of eruption of the per-
se mineralization disturbances in permanent successors, manent maxillary right lateral incisor was diagnosed and
with frequencies ranging from 41 to 77% (1). Innes (4) cone bean computed tomography was requested. Bond
analyzed intrusive injuries of primary incisors in chil- between the crowns of maxillary right central and lateral
dren under 4 years of age and found that over half of the incisors through enamel bridge was observed.
permanent successors were found to have one or more A multidisciplinary treatment plan, involving periodon-
developmental disturbances. In this case report, we des- tist, orthodontist and pediatric dentists, was outlined in
cribe the management and long term follow-up of se- an attempt to expose the teeth through gingivectomy for
quelae affecting permanent central incisor due to prior the orthodontic traction. During the gingivectomy pro-
intrusive luxation and subluxation of the corresponding cedure, an attempt was performed to display the crown
primary tooth. of the maxillary right lateral incisor, the junction be-
tween the crowns of the maxillary right lateral and cen-
Case Report tral incisor was separated using diamond bur, allowing
A healthy 5 years-old boy was referred to the Centre for the bracket bonding for orthodontic traction.
the Study and Treatment of Dental Trauma in Primary Traction of the lateral incisor was attempted using brac-
Dentition (NETRAD- Federal University of Pelotas, kets and later using cantilever systems. However, due to
Brazil), after 3 years and 5 month of follow-up in pri- lack of results through the traction attempts, new cone
vate dental clinic. Reportedly, at 21 month of age, he beam CT was requested and it was noticed that the ena-
had experienced a fall from the proper high, while riding mel bridge between central and right lateral incisor still
his scooter that caused subluxation of the primary right stayed (Fig. 2). Thus, periodontal surgery was conducted
and left maxillary central incisors, and partial intrusive and complete separation of the enamel bridge was obtai-
luxation of the primary maxillary right lateral incisor. ned, in an attempt to allow the eruption of the maxillary
Clinical and radiographic examination revealed crown right lateral incisor. Thereafter, indirect facet in compo-
discoloration of both primary maxillary right and left site resin was made to this element.
central incisors and the maintenance of the intrusion of Currently, the patient is 16 years (Fig. 3) and continues
the primary maxillary right lateral incisor. Also, mobili- in regular clinical and radiographic follow-up. The in-
ty of the primary maxillary right central incisor and pulp formed consent of the patient was obtained for this pu-
necrosis of the primary maxillary left central incisor blication.
was detected. Endodontic treatment was performed in
the primary maxillary left central incisor. Extraction of Discussion
the primary maxillary right lateral incisor was perfor- In the case here presented, a child suffered a severe in-
med, because of the lack of re-eruption. The patient was jury in primary teeth and had sequelae in the permanent
oriented to regular follow-up every 6 months. dentition, causing physical and emotional consequences
By the time the patient had eight years and 5 months to the children and the family. An analysis of records of
of age, developmental disturbances like hypoplasia and patients attending NETRAD showed that intrusion and
crown dilaceration of the permanent maxillary right cen- subluxation are the most common types of injury in this
tral incisor were confirmed, as previously observed ra- treatment center (5,6). . These injuries are frequently as-
diographically (Fig. 1). For aesthetic reasons, restorative sociated with sequelae, which can affect both the perma-
treatment was performed with resin composite for both nent successor and the traumatized tooth itself (1).
labial and palatal surfaces. After 2 years, in another fo- Spontaneous re-eruption is expected following intrusion

Fig. 1: (a) Clinical presentation of the child at 8 years of age showing hypoplasia and crown dilaceration
of the permanent upper right central incisor (b) Radiographic examination.

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existing union between the elements can be explained

by the approach and fusion of the enamel epithelium af-
ter traumatic shock, thus creating a “gate”, this began
to synthesize the enamel matrix, which just then being
produced in a single block, after the enamel maturation
phase remains the bridge between the dental elements.
The treatment of permanent incisors crown dilaceration
depends on the severity of the abnormality. It is essen-
tial to perform an accurate diagnosis in order to elect an
effective conduction reestablish function, aesthetics and
self-esteem of the patient. In this case, a composite resin
restoration to the maxillary right central incisor, using
an opaque color, was performed in order to mask the
characteristic yellow-brownish color (10).
In this report, in addition to the damage generated at the
maxillary right central incisor, the lateral on the same
Fig. 2: Cone beam computed tomography showing the enamel bridge side was impacted. In these cases the most common
between central and right lateral incisor still stayed after a first at- treatment options are surgical extrusion followed by
tempt of separation. (a) Vestibular view (b) Panoramic view (c) Ves- orthodontic traction (11), or extraction of the impacted
tibular view with removal bone tissue (d) Axial cutting. element followed by prosthetic rehabilitation (12). In the

Fig. 3: (a) Intra-oral photograph after restoration, (b) Periapical X-ray.

in primary teeth (7). In the present case, the extraction present case, orthodontic traction was attempted twice,
was performed because the tooth did not re-erupt. In but did not achieve the expected success, probably due
these cases, extraction is recommended because of the to the continuity of the enamel bridge. The extraction of
risk of damage presented to the permanent bud (8). Also, impacted element followed by prosthetic rehabilitation
according to the most up-to-date guideline (9), the di- was not applied in this case because the extraction of
rection of the apex displacement is essential to define tooth in a young patient would result in a horizontal and
the treatment in cases of intrusive luxation. If the apex / or vertical alveolar bone defect (13).
is displaced toward or through the labial bone plate, the Correct diagnosis is the key of successful treatment.
tooth is left for spontaneous repositioning, however if Uses of adjunct tools like radiographs are important to
the apex is displaced into the developing tooth germ, provide valuable information that may affect the treat-
tooth should be extracted. ment plan for the injured tooth. Panoramic examination
In this case, the severity of the injury, associated with is a very useful one, but provides only a two-dimensio-
the young age of the patient, caused alterations in shape nal picture of three-dimensional structures which may be
and color in the permanent successor, which caused a considered one of its limitations (14). Therefore, Cone
severe function and esthetic sequelae. The germ of the beam computed tomography (CBCT) provides multiple
permanent successor was in early stages of Odontoge- plans to identify with precision three-dimensional anato-
nesis. Probably, trauma promoted destruction of amelo- mical details, it has shorter exposure time, high resolu-
blasts in the enamel epithelium, favoring the occurren- tion, reduced image artifact, low radiation dose and high
ce of dilaceration and hypoplasia. Histologically, the accuracy (15). However, it must be indicated for specific

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situations and the high cost of this technology restricts Conflicts of interest
its use in most dental offices. None.
The periodic follow-up examinations facilitate and ex-
pedite the provision of adequate treatment for children
sustaining any sequelae in the permanent anterior teeth
following trauma in their predecessors (2). In this parti-
cular case, it was possible to identify an enamel bridge
formed between two dental elements, formed as a result
of the traumatic injury. The patient had fifteen years of
follow-up and the frequent monitoring enabled to detect
the consequences of deciduous and permanent teeth and
to intervene when necessary. Despite the difficulties, this
type of cases can be treated with success. A precise diag-
nosis, preferably involving a multidisciplinary team, is
of outmost importance to detect any possible alterations
resulting from dental trauma.

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