Drs. Ruviére and Costa are post doctoral students, and Dr. Cunha is adjunct professor, all in the Department of Pediatric and Social Dentistry, School of Dentistry of Araçatuba, São Paulo State University (UNESP), Araçatuba, São Paulo, Brazil. Correspond with Dr. Cunha at email@example.com J Dent Child 2009;76:87-91
INTRUSION Apical displacement of tooth into the alveolar bone. The tooth is driven into the socket, compressing the periodontal ligament and commonly causes a crushing fracture of the alveolar socket
Dental traumatic injuries in infants and young children are common. Retrospective and prospective studies related that prevalence of these injuries involving the primary dentition ranged from 4% to 33%.
color change, pulp necrosis, obliteration of the pulp canal, gingival retraction, primary tooth displacement, pathological root resorption, and premature loss of the primary tooth.
tooth displacement within the socket and can affect the crown, root, or entire permanent tooth germ. anomalous development of the permanent teeth, with a frequency between 18% and 69%.
The aim of diagnosis and treatment of traumatic injuries in primary teeth is to manage pain and prevent sequelae for the developing permanent tooth germ
If the apex is displaced toward or through the labial bone plate, the tooth is left for spontaneous re-eruption. If the apex is displaced toward the permanent tooth germ, the tooth should be extracted.
To describe the treatment of a primary maxillary right lateral incisor in which spontaneous re-eruption after severe traumatic intrusion occurred and its possible consequences on the developing successive permanent germs.
The research protocol was submitted for review to the Ethics in Human Research Committee of the School of Dentistry of Araçatuba, São Paulo State University, Araçatuba, São Paulo, Brazil, and the case report design was approved. 18-month-old male
The extraoral examination revealed a mild edema and several small cuts and lacerations on the maxillary and mandibular lips. The intraoral examination revealed complete intrusion of the primary maxillary right lateral incisor, crown fracture of the primary maxillary right central incisor without pulp involvement, and disruption of the superior labial frenum, with no pain related.
The primary maxillary right lateral incisor’s apex was dislocated into the vestibule, indicating a labial displacement direction
After 30 days, although the tooth had not initiated the re-eruption process, clinical examination showed a normal aspect, characterized by no dental crown discoloration, mobility, or pain. Radiographic examination also revealed normal aspects
Sixty days following the dental trauma, the beginning of spontaneous re- eruption of the primary maxillary right lateral incisor was observed clinically.
Twelve months after the trauma, radiograph evaluations showed that the root resorption was stabilized and clinical findings revealed no pain, discoloration, or mobility of the dental crown. The endodontic intervention was not performed.
The parents were informed of the sequelae of the primary intruded tooth’s condition and morphological alterations in the permanents teeth.
If the apex is dis-placed labially, the apical tip can be seen radiographically with the tooth appearing shorter than its contralateral If the apex is displaced palatally towards the permanent tooth germ, the apical tip cannot be seen radiographically and the tooth appears elongated.
to allow spontaneous re-eruption except when displaced into the developing successor
to reposition passively, actively or surgicallyand then to stabilize the tooth with a splint for up to 4 weeks
For immature the objective is to allow for spontaneous eruption In mature teeth, the goal is to reposition the tooth with orthodontic or surgical extrusion and initiate endodontic treatment within the first 3 weeks of the traumatic incidence
The preference for intrusion into the permanent maxillary central and lateral incisor appears to be related to the common fall direction in which these teeth are generally the first to make contact with extraoral objects.
Depending on the vestibular curvature of the primary teeth’s root and the impact’s direction, the apexes of these teeth are usually dislocated into the vestibular. The most common initial treatment for traumatically intruded primary teeth is to wait for spontaneous re-eruption.
timing of seeking care the family’s eagerness to maintain the teeth, and the patient’s age
Gondim et al, who evaluated 22 intruded teeth and showed a total re-eruption in 43% of cases, partial re-eruption in 47% of cases, and no re-eruption in 11% of cases.Gondim JO, Moreira Neto JJS. Evaluation of intruded primary incisors. Dent Traumatol 2005;21:131-3.
In a follow-up study of 123 intruded primary incisors, total re-eruption occurred in 84% of the completely intruded teeth and in 92% of those who had suffered partial intrusion.Borssén E, Holm A-K. Treatment of traumatic dental injuries in a cohort of 16-year- olds in northern Sweden. Endod Dent Traumatol 2000;16:276-81.
In addition, in a clinical study of 123 intruded teeth available for follow-up evaluation, 88% re-erupted fully, 10% did not return to the occlusal plane, and 2% failed to re-erupt due to ankylosis Holan G, Ram D. Sequelae and prognosis of intruded primary incisors: A retrospective study. Pediatr Dent 1999;21:242-7.
In a study of 11 cases of primary intruded tooth Seven cases have been observed satisfactory without surgical treatments such as re-positioning and fixation, and all those re- erupted to the occlusal level of the contra- lateral side within 1.5 year. Otherwise, 4 cases treated with re-positioning and fixation revealed periapical periodontitis in radiographic feature, alveolar abscess formation, or discoloration. Hirata et al. Management of Trauma of Primary Tooth: Report of Intrusion Case. J.Hard Tissue Biology 2005;14(4):361-362.
Diab et al described that when the tooth was intruded completely, the tooth should be extracted because re- eruption could not be expected. On the other hand, Holan et al reported 108 of 123 intruded teeth were re-erupted spontaneously. Diab M. and Elbadrawy H.E.: Intrusion injuries of primary incisors. Part : Review and Management. Quintessennce Int 31:327-334, 2000
Several studies support that the permanent tooth germ’s malformation may be the result of severe intrusion by the primary tooth and invasion of the developing germ during the earliest phases of odontogenesis, when the child is between 1 and 3 years old
The type of traumatic primary tooth injury combined with the child’s age at the time of the injury can indicate the probability of subsequent damages to the primary tooth or permanent tooth germ involved. The importance of regular follow-ups should be emphasized to evaluate healing, oral hygiene, infection control, and evolution of the case
In this case report, secondary damage on the permanent maxillary right central and lateral incisors’ germs was observed radiographically. The extent and type of actual damage was not definitively established.
Ruviére, Costa, Cunha. Conservative Management of Severe Intrusion in a Primary Tooth: A 4-year Follow-up. J Dent Child 2009;76:87-91. Guideline on Management of Acute Dental Trauma. AAPD 201;33(6): 220-28. Gondim JO, Moreira Neto JJS. Evaluation of intruded primary incisors. Dent Traumatol 2005;21:131-3. Borssén E, Holm A-K. Treatment of traumatic dental injuries in a cohort of 16-year-olds in northern Sweden. Endod Dent Traumatol 2000;16:276-81. Holan G, Ram D. Sequelae and prognosis of intruded primary incisors: A retrospective study. Pediatr Dent 1999;21:242-7. Diab M. and Elbadrawy H.E.: Intrusion injuries of primary incisors. Part : Review and Management. Quintessennce Int 2000;31:327-334. Hirata et al. Management of Trauma of Primary Tooth: Report of Intrusion Case. J.Hard Tissue Biology 2005;14(4):361-362.