- An 8-year-old girl fractured her upper right permanent central incisor after slipping and hitting her mouth on a table at school. - Radiographs revealed a severe intrusive luxation of the tooth with an indistinct periodontal ligament space and an immature root with an open apex. - The tooth was diagnosed with an intrusive luxation and showed early signs of pulp necrosis. It was treated with rapid orthodontic extrusion followed by pulp extirpation and root canal treatment once access to the canal was possible.

1. TRAUMA TO AN IMMATURE
INCISOR
By Dr.Hyder Mohammed
Case presentation

2. An 8-year-old girl has fractured her upper right
permanent
central incisor tooth.

3. Complaint
The child is brought in as an emergency by her mother, complaining of a
broken front tooth.
History of complaint
Two hours prior to presentation the child had slipped at school, hitting her
mouth. One front tooth appears to be broken.
Medical history
The child is healthy.
Dental history
The child has attended the dentist irregularly, has no caries and no experience
of operative dentistry. Her mother states that the broken tooth had not
appeared normal and may have been decayed.

4. Did the patient lose consciousness?
admitted for 24 hours of observation. in this case the patient did not lose
consciousness.
Was a piece of the tooth broken off and was it found?
this case no fragment was found.
Has the patient suffered trauma previously?
Previous trauma to this tooth could have resulted in arrested root
development, disturbed crown formation or pathological mobility prior to
this incident, depending on the age and stage of dental development at the
time. Such changes could affect treatment and might explain the parent’s
observation that the tooth was not normal. In this case no previous trauma
could be recalled by the parent.

5. Was the damaged tooth fully erupted before the accident?
In early mixed dentition, incisors on opposite sides of the mouth may be at
different stages of eruption. At this age it would be expected that eruption
would be complete but there is wide variation in eruption date and rate. It
would be possible to misinterpret incomplete eruption as an intrusion injury if
the original degree of eruption were not known. In this case, the child’s
mother reported that both front teeth were fully erupted.
What object or surface did the child hit with her mouth?
Injury on surfaces such as playgrounds, roads and pavements carries the
risk of contaminating the wound with dirty particulate material. Sometimes
such foreign material even enters intraoral wounds. Thorough debridement
would then be required. It would also be necessary to check the child’s
immunization status for tetanus prophylaxis and arrange a booster dose if
required. In this case, the child hit the edge of a table.

6. Examination
Extra-oral examination
The child is distressed but is readily examined. There is some slight swelling of the
upper lip but no external abrasions or lacerations.
Intraoral examination
The appearances of the teeth , What do you see?
erythematous and swollen
less than 1 mm of the tooth is visible
The visible fragment appears to be an
intact incisal edge

7. What additional examination(s) would you perform?
injury to the adjacent incisors and teeth in the lower labial
segment should be investigated.
• Vitality,
• mobility,
• tenderness to percussion
• a periodontal probe should be gently inserted into the labial
gingival sulcus to confirm or exclude the presence of a deep
pseudo-pocket which would indicate traumatic displacement.

8. Child abuse

9. What is your initial differential diagnosis?
There are two main possibilities
• The central incisor has been almost completely intruded
(intrusive luxation)
• Crown has been fractured horizontally at gingival level.

10. Investigations
Radiographs are required to visualize the intruded/ fractured tooth and
to assess damage to it and the adjacent teeth. Periapical views should be
taken of all upper incisors to detect possible root fracture and to assess
the stage of root development of the incisors. In intrusion injuries the force
of the blow is directed upwards so that it is unlikely that the lower incisors
have been damaged.
What does the radiograph show?
The radiograph shows a severe intrusive
luxation of the maxillary right permanent
incisor. The periodontal ligament space is
indistinct or obliterated in part. There is no
crown or root fracture visible, and the root is
immature with a wide open apex.

11. Tests of vitality of all incisors are required.
if the patient is sufficiently composed to allow it, all the incisors should be checked for
vitality, preferably by electric pulp testing. Teeth recently subjected to trauma may not
respond to testing (‘concussion’) and testing teeth with open apices may give an
artificially low reading. However, it is important to take a baseline reading soon after the
injury so that if vitality does not recover, treatment may be instituted without delay.
What is your final diagnosis?
The patient has an intrusive luxation to the permanent central
incisor. This tooth also has several discrete hypoplastic enamel
defects that were present before the accident.

12. What types of tissue injury result from intrusion and what are their
complications?

13. Will the tooth re-erupt or should it be surgically repositioned?
all mature teeth (closed apex) and over 60% of immature teeth
become nonvital as a result of intrusive luxation. Therefore,
it is advisable to reposition the tooth as rapidly as possible so that access to
the pulp chamber can be facilitated before pulp necrosis occurs. intruded teeth
with open apices do have the potential for re-eruption, but if this has not
commenced within 1 week, intervention is required. There is at present no
evidence to indicate the optimal treatment for the intrusive luxation of permanent
teeth. Given sufficient cooperation, immediate surgical repositioning of the tooth
will immediately restore the appearance. This should be followed by a short period
of splinting of 7–10 days. This option may, however, increase the likelihood of
external root resorption and loss of marginal bone support. relatively rapid
orthodontic extrusion over a period of 3–4 weeks is considered less traumatic and
less likely to induce resorption.

14. In this case, spontaneous eruption was awaited, but was
very slow. Electric pulp testing indicated early pulp necro-
sis. The tooth was then extruded rapidly with a simple
orthodontic appliance engaged on to a bracket attached to
the labial surface of the intruded tooth. As soon as there
was adequate access to the pulp chamber, the necrotic pulp
was extirpated, the canal cleaned and obturated with non-
setting calcium hydroxide paste.

15. What immediate treatment is indicated?
immediate treatment aims to prevent subsequent external root resorption,
preserve marginal bone support and prevent sepsis. Teeth with a closed apex
should be treated by immediate pulp extirpation and placement of a non-setting
calcium hydroxide root canal dressing. immature teeth should be monitored for
spontaneous re-eruption and loss of vitality. a 5-day course of systemic antibiotics
should be prescribed, and the false gingival pocket surrounding the intruded
crown gently irrigated with chlorhexidine.

17. How would your management have differed if the patient had been a 3-year-old
child with an intruded primary incisor?
Mild intrusive luxation injuries in the primary dentition may be treated with
reassurance and observation though parents should always be warned that damage
to the permanent successor is common. Partial or sometimes total re-eruption over
the following months is usual.
However, extraction should be performed without delay if a combination of
periapical and lateral radiographs demonstrate that the deciduous tooth has
impinged on the follicle of the underlying tooth or if there is subsequent loss of
vitality. as in the permanent dentition, vitality must be monitored carefully if the
apex is closed at the time of injury. Pulp tests in young children are often unreliable
because of lack of understanding, and a close watch must be kept for colour
change.