10.59987/ads/2017.3.131-138
In the case reports, two different approaches have been described to treat the developmental disturbances in the maxillary central incisors due to trauma to its predecessor. The treatment plan was chosen according to the type and severity of the malformations, the exact location and the morphology of the involved teeth. In the first case, the disimpaction of the maxillary right central incisor was achieved with the combined of surgical and orthodontic therapy, that was planned in two consecutive stages. In the second case the severe root angulation and the failure of the previous orthodontic traction made impossible the repositioning of the upper right central incisor, which was surgical removed.
application/pdf
1971-1441
50
3
en
M. P. Cristalli 
https://creativecommons.org/licenses/by-nc-nd/4.0
Annali di stomatologia
tooth extraction
Surgical approach to malformation of maxillary central incisor following trauma to its predecessor. Two case reports
Text.Serial.Journal
https://www.annalidistomatologia.eu/ads
8
Case Report
2022-08-10
2022-08-10
2017-09-01
2023-12-04
131-138
Ann Stomatol (Roma)
M. P. Cristalli 
2017
10.59987/ads/2017.3.131-138
131
1971-1441
3
tooth extraction
en
138
Surgical approach to malformation of maxillary central incisor following trauma to its predecessor. Two case reports
https://www.annalidistomatologia.eu/ads/article/download/50/38
8
                                                                                                      Case report


    Surgical approach to malformation of maxillary
    central incisor following trauma to its predecessor.
    Two case reports




                                                                                               li
                                                                                             na
                                                             tition ranges from 12 to 74% (1-5).
                                                             The most common cause of trauma is falls, and the
    Gerardo La Monaca1, DDS, PhD

                                                             highest incidence of injuries occurs before the age of
    Iole Vozza2, DDS, PhD

                                                             2 years, as psychomotor development and poor mo-
    Susanna Annibali2, MD, DD




                                                                                           io
                                                             tor skill predispose children to fall (5-8). At this age
    Rita Giardino2, DDS, PhD

                                                             there are no significant differences in the prevalence
    Nicola Pranno2, DDS, PhD

                                                             among boys and girls (6, 8, 9). The injuries of primary
    Maria Paola Cristalli3, DDS, PhD




                                                                       az
                                                             dentition followed by a higher incidence of develop-
    1 Department of Sense Organs, “Sapienza”, Universi-      mental anomalies in the permanent dentition are
    ty of Rome, Rome, Italy                                  avulsion and intrusive luxation (3-5, 7, 10-12).
    2 Department of Oral and Maxillo-Facial Sciences,        These types of injury are related to the high resilience
    “Sapienza”, University of Rome, Rome, Italy              and flexibility of the primary teeth supporting struc-




                                                                     rn
    3 Department of Biotechnologies and Medical Surgical     tures, the large volume of teeth in relation to the bone
    Sciences, “Sapienza”, University of Rome, Rome, Italy    and the short roots (1, 6).
                                                             The sequelae on the permanent teeth depends on the




                                                      te
                                                             direction of the traumatic force, the type and the
                                                             severity of trauma, the degree of primary root resorp-
    Gerardo La Monaca                                        tion and the developmental stage of the permanent
    Corresponding author:

    “Sapienza” University of Rome                            tooth at the time of the injury, and mainly to the
                                                    In
    Via Caserta 6                                            child’s age (Tab. 1) (1, 4, 13). The child’s age was re-
    00161 Rome, Italy                                        ported to have a statistically significant association
    Tel.: +39 06 49976651                                    with the severity of the developmental sequelae in the
    Fax: +39 06 44230811                                     permanent maxillary central incisors: lower the age
                               ni

    E-mail: gerardo.lamonaca@uniroma1.it                     greater the severity (4, 12).
                                                             This may be explained as the germ of the permanent
                                                             maxillary central incisor in the early stages of devel-
                             io


                                                             opment is localized palatally and above the apex of
                                                             the deciduous predecessor (14). Between 3-5 years
    Summary

                                                             of age this tooth change its eruption pathway
                                                             proceeding forward and downward and its crown be-
                           iz



    In the case reports, two different approaches have

                                                             coming closer to the resorbing primary root (14).
    been described to treat the developmental distur-

                                                             Furthermore in this area the presence of the
    bances in the maxillary central incisors due to trau-

                                                             connective tissue, that is not permeable to the
            Ed




    ma to its predecessor.

                                                             displacement of the primary teeth, infection or
    The treatment plan was chosen according to the

                                                             necrosis explains the risk of developing disturbances
    type and severity of the malformations, the exact

                                                             in the succeeding permanent teeth after injuries to
    location and the morphology of the involved teeth.

                                                             their predecessors (1, 14).
    In the first case, the disimpaction of the maxillary

                                                             The purpose of the present report is to describe two
    right central incisor was achieved with the com-

                                                             cases of malformation of maxillary central incisor fol-
 IC




    bined of surgical and orthodontic therapy, that was

                                                             lowing traumatic injury in its predecessor, in which
    planned in two consecutive stages.

                                                             different approaches were adopted.
    In the second case the severe root angulation and
    the failure of the previous orthodontic traction
    made impossible the repositioning of the upper
C




    right central incisor, which was surgical removed.
                                                             Case reports
    Key words: tooth injuries, deciduous tooth, perma-

                                                             A 7-year-old boy was referred to the “Sapienza”
    nent dentition, tooth abnormalities, tooth unerupt-      I Case
©




                                                             Rome University, Department of Oral and Maxillofa-
    ed, tooth extraction.

                                                             cial Sciences, Oral Surgery Unit by his parents. The
                                                             chief complaint was the eruption delay of the perma-
                                                             nent maxillary right central incisor.
    Introduction

    The prevalence of developmental disturbances in up-      The past medical history was negative, except for
    per central incisors due to trauma in the primary den-   traumatic injury to the premaxilla at 3-year-old age.

    Annali di Stomatologia 2017;VIII(3):131-138                                                                  131
    G. La Monaca et al.


    Table 1. Sequelae on the permanent teeth following trauma to primary teeth

            Pathologic Alteration           Clinical Features       Clinical Features                                    Age
     White or yellow-brown discoloration    The affected enamel appears as a white or yellow-brown area,               2-5 years
                  of enamel                 extent varying, sharply demarcated, without detectable defects in
                                            the enamel surface.




                                                                                                            li
                                            The white colour was due to a lower mineral statement and the
                                            yellow-brown colour was due to a bleeding spread where the




                                                                                                          na
                                            enamel is developing.
     White or yellow-brown discoloration    Hypoplastic defects may be caused by a localized damage to the              2 years
      of enamel with circular enamel        enamel matrix during the secretory phase of the ameloblasts,
                  hypoplasia                before the mineralization is completed.
                                            This malformation is characterized by a narrow horizontal groove




                                                                                                        io
                                            around the crown in cervical position with respect to the areas with
                                            white or yellow-brown discoloration.
              Crown dilaceration            Crown dilaceration is a deviation of the crown in relation to the long      1.5- 3.5




                                                                                 az
                                            axis of the tooth as a consequence of the traumatic non-axial                years
                                            displacement between unmineralized and mineralized tissues of
                                            the developing tooth germ
                                            The curve can be located at the cervical portion, midway along the
                                            root or even just at the apex of the root. Half of these teeth become




                                                                               rn
                                            impacted, whereas the remaining half erupts normally either in
                                            facial or in lingual version.
                Root duplication            Root duplication is the result of a traumatic division of the cervical     2-5 years




                                                           te
                                            loop that develops two separate roots. Radiographically, it can be
                                            demonstrated a mesial and distal root, which extend from a
                                            partially formed crown. Histologically there is a calcium-traumatic
                                            line separating the hard tissue formed before the injury.
          Vestibular root angulation or
                                                         In
                                            Vestibular root angulation is a marked curvature confined to the           2-5 years
                  dilaceration              root, due to the gradual change in the direction of development.
                                            The malformed tooth is usually impacted and the crown palpable in
                                            the labial sulcus.
                                            This malformation is unique feature of the maxillary central
                               ni
                                            incisors.
           Lateral root angulation or       Lateral root angulation or dilaceration are mesial or distal bending       2-5 years
                  dilaceration              of the root of the tooth. The dilaceration is caused when the impact
                             io

                                            force is transferred along an imaginary oblique line that goes
                                            through the incisal edge of the permanent incisor and causes this
                                            crown to turn upwards into its tooth follicle. The permanent incisor
                                            root already formed wheels and it creates an unusual angle
                           iz



                                            between the pre- and post-traumatic parts of the tooth.
       Partial or complete arrest of root   Partial or complete arrest of root formation is a rare complication        1-3 years
                   formation                characterized by missing eruption or mobility, as a result from
            Ed




                                            inadequate periodontal support.
                                            Normal root development can be compromised by direct injury to
                                            Hertwig’s epithelial root sheath resulting in a calciotraumatic line
                                            separating the hard tissue deposited before and after the injury.
      Sequestration of permanent tooth      This rare complication is characterized by swelling, suppuration           1-3 years
                   germs                    and fistula formation.
 IC




                                            Radiographic examination discloses osteolytic changes around the
                                            tooth germ, including disappearance of the outline of the dental
                                            crypt and expanded cortical alveolar bone.
            Disturbance in eruption         Disturbances in permanent tooth eruption include: impaction,               1-3 years
                                            ectopic eruption, delayed eruption, scar plate formation and
C




                                            ankylotic primary teeth.
                                            Impaction is very common in the cases in which there is crown or
                                            the root malformations.
                                            The ectopic eruption is related with the early loss of primary
©




                                            incisors due to lack of eruption guidance. The delayed eruption is
                                            related with the abnormal changes in the connective tissue after
                                            the early loss of primary incisors (avulsion or extraction).
          Odontoma-like malformation        This malformation occurs during early stage of odontogenesis and           1-3 years
                                            affect the morphogenetic stages of ameloblastic development.
                                            The hystologic analysis shows a conglomerate of hard tissue,
                                            having the morphology of a complex odontoma or separate tooth
                                            elements.


    132                                                                                  Annali di Stomatologia 2017;VIII(3):131-138
    Management of a permanent tooth after trauma to deciduous predecessor


    The panoramic radiograph showed in the right side of        started to correct the patient’s malocclusion and to
    the maxillary jaw the presence of the deciduous in-         place the tooth into its proper position in the dental
    cisors and the inclusion of the permanent central in-       arch (Fig. 5).
    cisor with the crown underneath the anterior nasal
    spine and with its incisal edge upwards. In the left
    side the rotated permanent left central incisor and the     A 12-year-old boy was referred to the “Sapienza”
                                                                II Case

    lateral primary incisor were present (Fig. 1).              Rome University, Department of Oral and Maxillofa-




                                                                                                   li
    The computer tomography confirmed the position of           cial Sciences, Oral Surgery Unit by his parents, com-




                                                                                                 na
    the right central incisor across the premaxilla and         plaining of the failure of surgical-orthodontic reposi-
    showed its incomplete root formation, developing on         tioning of the maxillary right central incisor lasted
    the long axis of the crown (Fig. 2).                        three years. The child was healthy and his medical
    In agreement with the orthodontist, it was decided to       history did not reveal any important information. The
    try the surgical exposure and orthodontic traction of       parents reported that the patient at the age of 22




                                                                                               io
    the affected tooth, before performing the orthodontic       months underwent intrusion of central primary incisor,
    treatment for the correction of the malocclusion and        spontaneously re-erupted after 3 weeks.
    the repositioning of the right central incisor into prop-   The intraoral examination revealed the permanent




                                                                          az
    er position.                                                right central incisor missing, the partial loss of its
    In view of the incisor position, surgical exposure was      space due to the migration of the adjacent teeth and
    planned in two stages.                                      the crown of the maxillary right lateral incisor affected
    In the first a full-thickness buccal flap was made un-      by white or yellow-brown discoloration of enamel and




                                                                        rn
    der local anaesthesia to gain access to cortical plane      circular enamel hypoplasia (Fig. 6).
    of the maxilla, and the primary incisors were extract-      In periapical radiograph, the crown of the maxillary
    ed (Fig. 3a). After bone removal, the crown was ex-         right central incisor appeared with its incisal edge up-
    posed and an orthodontic bracket with ligature wire         wards underneath the anterior nasal spine (Fig. 7).




                                                         te
    was bonded onto the palatal surface of the maxillary        The cross-sectional images of the computer tomogra-
    right central incisor (Fig. 3b). The flap was reposi-       phy confirmed the buccal angulation with a severe
    tioned and sutured. Two weeks later, orthodontic            curvature, already suspected in the conventional ra-
                                                       In
    forces were applied to pull the crown in buccal and         diograph and provided valuable information about the
    horizontal direction, in order to move away the incisor     morphology of the root (Fig. 8).
    from the roots of the adjacent teeth.                       In this case the severe root angulation and the failure
    The second surgical stage was performed when the            of the previous orthodontic traction made impossible
    crown was visible through the buccal mucosa (Fig.           the central incisor repositioning, therefore its surgical
                               ni

    4a). Using an apically repositioned flap, the crown         removal was preferred.
    was exposed and a bracket was bonded on its labial          A full-thickness buccal flap was reflected, the ostecto-
    surface to change direction to orthodontic traction in      my was carried out on the labial cortical plane to ex-
                             io


    order to straighten the tooth (Fig. 4b).                    pose the crown completely, and the impacted tooth
    After 14 months the recovering of the maxillary right       was easily removed (Fig. 9a, b). The debridement of
    incisor was achieved and the orthodontic therapy was        the scars following to the previous intervention of the
                           iz
            Ed




                                                                                             Figure 1. Panoramic radio-
                                                                                             graph showing in the right
                                                                                             side of the maxilla the de-
                                                                                             ciduous incisors and the in-
                                                                                             clusion of the permanent
                                                                                             central incisor and in the left
 IC




                                                                                             side the rotated permanent
                                                                                             left central incisor and the
                                                                                             lateral primary incisor.
C
©




    Annali di Stomatologia 2017;VIII(3):131-138                                                                        133
    G. La Monaca et al.




                                                                                                      li
                                                                                                    na
                                                                                                  io
                                                                             az
                                                                           rn
                                                         te
                                                       In
                              ni
                            io
                          iz



    Figure 2. Computer tomography showing the position of the right central incisor across the premaxilla and its incomplete
           Ed




    root formation.




                                                                                                    Figure 3a, b. The first
                                                                                                    stage of the surgical ex-
 IC




                                                                                                    posure of the maxillary
                                                                                                    right central incisor: a) a
                                                                                                    full-thickness buccal flap
                                                                                                    and the extraction of the
C




                                                                                                    primary incisors were
                                                                                                    carried-out; b) the crown
                                                                                                    was exposed and an or-
                                                                                                    thodontic bracket was
                                                                                                    bonded onto its palatal
©




                                                                                                    surface.




    134                                                                             Annali di Stomatologia 2017;VIII(3):131-138
    Management of a permanent tooth after trauma to deciduous predecessor


                                                                                                   Figure 4a, b. The second
                                                                                                   surgical stage: a) the
                                                                                                   crown was visible through
                                                                                                   the buccal mucosa; b) the
                                                                                                   crown was exposed using
                                                                                                   an apically repositioned
                                                                                                   flap and a bracket was




                                                                                                       li
                                                                                                   bonded on its labial sur-
                                                                                                   face.




                                                                                                     na
                                                                                                   io
                                                                             az
                                                                           rn
                                                           te
                                                         In
                               ni

    Figure 5. The recovering of the maxillary right central in-
    cisor.
                             io


    crown exposure was performed and the site, covered
    by periodontal dressing, was left healing by sec-
                           iz



                                                                  Figure 6. The intraoral examination: the permanent right
    ondary intention (Fig. 9c, d).                                central incisor missing, the partial loss of its space due to
                                                                  the migration of the adjacent teeth and the crown of the
            Ed




                                                                  maxillary right lateral incisor affected by white or yellow-
                                                                  brown discoloration of enamel and circular enamel hy-
                                                                  poplasia.
    Discussion

    Developmental disturbances of permanent incisors
    following trauma to the primary dentition have a phys-
    ical, aesthetic and psychological impact both for chil-       lationship between deciduous teeth and the perma-
 IC




    dren and their parents.                                       nent successors.
    In these cases, the choice of the appropriate treat-          The combined surgical and orthodontic therapy is the
    ment modalities is very important and depends on the          method of choice for many clinicians. The success
    type of lesion, the exact location and the morphology         rate of this treatment depends on the degree of mal-
C




    of the involved teeth.                                        formation, position and root formation of the tooth.
    Although panoramic or periapical radiographs are              Studies have also shown that the bone loss after or-
    conventionally used for preoperative examination,             thodontic treatment and the chance of injury to the
    more accurate information are achieved with comput-           tooth during traction is directly connected to the
©




    er tomography, because this methodic produces                 quantity of bone removed during surgical exposure.
    three-dimensional images without enlargement or su-           However with the combined surgical/orthodontic ther-
    perimposition of anatomical structures (13).                  apy, ankylosis, pulp necrosis, root resorption, gingival
    Infact to allow a correct diagnosis it is mandatory to        recession, delay in periodontal healing, bone loss
    determine the exact position of the involved teeth,           and decrease in the width of keratinized gingiva may
    their morphology and degree of root formation, the re-        occur (14).


    Annali di Stomatologia 2017;VIII(3):131-138                                                                            135
    G. La Monaca et al.


                                                                    When surgical exposure and orthodontic traction fail
                                                                    or they are undesirable or impossible, such as in the
                                                                    case of odontoma like-malformation, the only option
                                                                    is the surgical tooth extraction as soon as possible.
                                                                    However, if the location is deep in the maxillary bone,
                                                                    without any eruption disturbance of the adjacent
                                                                    teeth, it is possible to decide to not remove the mal-




                                                                                                        li
                                                                    formed tooth, but clinical follow-ups and periodic ra-
                                                                    diographs to rule out any pathologic development are




                                                                                                      na
                                                                    necessary (15). This kind of non-treatment has the
                                                                    advantage of not exposing the patient to extensive
                                                                    surgery under general anesthesia, but it requires re-
                                                                    call examinations over time and annual repetitive ra-




                                                                                                    io
                                                                    diation exposure (15).




                                                                              az
                                                                    Conclusion

                                                                    Determining prognosis and treatment planning for a
                                                                    retained tooth are often difficult tasks. Two different
                                                                    treatments approaches to manage a traumatized per-




                                                                            rn
                                                                    manent tooth need to be considered: surgical expo-
                                                                    sure with orthodontic traction vs extraction and pros-
                                                                    thetic replacement with fixed bridge or implant place-




                                                             te
                                                                    ment later when growth had ceased.
    Figure 7. Periapical radiograph showing the crown of the        An appropriate diagnosis with both clinical and radio-
    maxillary right central incisor with its incisal edge upwards   graphic examination is needed for the choice and the
    underneath the anterior nasal spine.                            success of the treatment plan.
                                                           In
                               ni
                             io
                           iz
           Ed
 IC
C
©




    Figure 8. Computer tomography showing the permanent right central incisor with a marked buccal curvature of its root.


    136                                                                               Annali di Stomatologia 2017;VIII(3):131-138
    Management of a permanent tooth after trauma to deciduous predecessor




                                                                                                                 li
                                                                                                               na
                                                                                                             io
                                                                                     az
                                                                                   rn
                                                                te
                                                              In
                                ni

    Figure 9a-d. Surgical intervention: a) extraction of the maxillary right central incisor; b) clinical view of the extracted tooth; c)
                              io


    debridement of the scars following to the previous intervention of the crown exposure; d) periodontal dressing.

    The sequelae to the permanent dentition after trauma                      predecessors: a longitudinal study of 8 years. Dent Traumatol.
                            iz



    to the primary dentition may require a multidisci-                        2009;25(3):300-304.
    plinary approach involving Pediatric Dentist, Or-                    2.   Arenas M, Barbería E, Lucavechi T, Maroto M. Severe trau-
    thodontist, Periodontist, Oral Surgeon and Prostho-                       ma in the primary dentition-diagnosis and treatment of se-
            Ed




                                                                              quelae in permanent dentition. Dent Traumatol. 2006;22(4):
    dontist.
                                                                              226-230.
                                                                         3.   Sennhenn-Kirchner S, Jacobs HG.Traumatic injuries to the
                                                                              primary dentition and effects on the permanent successors
    Conflict of interest and source of funding                                - a clinical follow-up study. Dent Traumatol. 2006;22(5):237-
                                                                              241.
 IC




    statement
                                                                         4.   Lenzi MM, Alexandria AK, Ferreira DM, Maia LC. Does trau-
    The Authors have stated explicitly that there are no                      ma in the primary dentition cause sequelae in permanent suc-
    conflicts of interest in connection with this article.                    cessors? A systematic review. Dent Traumatol. 2015;31(2):79-
                                                                              88.
                                                                         5.   Bardellini E, Amadori F, Pasini S, Majorana A. Dental Anoma-
C




                                                                              lies in Permanent Teeth after Trauma in Primary Dentition.
                                                                              J Clin Pediatr Dent. 2017;41(1):5-9.
    Authors declarations
                                                                         6.   Coutinho TC, Cajazeira MR. Retrospective study on the oc-
    All Authors gave final approval and agree to be ac-                       currence of primary incisor trauma in preschool children of
    countable for all aspects of the work.
©




                                                                              a low-income area in Brazil. Eur J Paediatr Dent. 2011;12(3):
                                                                              159-162.
                                                                         7.   Da Silva Assunção LR, Ferelle A, Iwakura ML, Cunha RF.
                                                                              Effects on permanent teeth after luxation injuries to the pri-
                                                                              mary predecessors: a study in children assisted at an emer-
    References
    1.   Do Espírito Santo Jácomo DR, Campos V. Prevalence of se-             gency service. Dent Traumatol. 2009;25(2):165-170.
         quelae in the permanent anterior teeth after trauma in their    8.   Altun C, Cehreli ZC, Güven G, Acikel C. Traumatic intrusion


    Annali di Stomatologia 2017;VIII(3):131-138                                                                                        137
    G. La Monaca et al.


        of primary teeth and its effects on the permanent successors:          teeth and sequelae on the permanent successors. Dent Trau-
        a clinical follow-up study. Oral Surg Oral Med Oral Pathol Oral        matol. 2005; Dec;21(6):320-323.
        Radiol Endod. 2009;107(4):493-498.                                 13. Gurgel CV, Lourenço Neto N, Kobayashi TY, Garib DG, da
    9. Cardoso M, de Carvalho Rocha MJ. Traumatized primary                    Silva SM, Machado MA, et al. Management of a permanent
        teeth in children assisted at the Federal University of San-           tooth after trauma to deciduous predecessor: an evaluation
        ta Catarina, Brazil. Dent Traumatol. 2002;18(3):129-133.               by cone-beam computed tomography. Dent Traumatol.
    10. De Amorim Lde F, Estrela C, da Costa LR. Effects of trau-              2011;27(5):408-442.




                                                                                                                     li
        matic dental injuries to primary teeth on permanent teeth-a        14. Topouzelis N, Tsaousoglou P, Pisoka V, Zouloumis L. Di-
        clinical follow-up study. Dent Traumatol. 2011;27(2):117-121.          laceration of maxillary central incisor: a literature review. Dent




                                                                                                                   na
    11. Renton T, Yilmaz Z, Gaballah K. Evaluation of trigeminal nerve         Traumatol. 2010;26(5):427-433.
        injuries in relation to third molar surgery in a prospective pa-   15. Shaked I, Peretz B, Ashkenazi M. Development of odontoma-
        tient cohort. Recommendations for prevention. Int J Oral Max-          like malformation in the permanent dentition caused by in-
        illofac Surg. 2012;41:1509-1518.                                       trusion of primary incisor-a case report. Dent Traumatol.
    12. Christophersen P, Freund M, Harild L. Avulsion of primary              2008;24(3):395-397.




                                                                                                                 io
                                                                                       az
                                                                                     rn
                                                                   te
                                                                 In
                                 ni
                               io
                             iz
            Ed
 IC
C
©




    138                                                                                          Annali di Stomatologia 2017;VIII(3):131-138
