Developmental disturbances in permanent

successors after intrusion injuries

to maxillary primary incisors
M. L. ODERSJÖ*-**, G. KOCH**

SUMMARY. Aim The aim of the present study was to report the frequency of developmental disturbances in
permanent teeth as a result of intrusive injuries to the primary predecessors and relate this to the degree of
intrusion, the age of the child, the developmental stage of permanent germ and the treatment given. Methods
Seventy children with previous intrusive trauma of their maxillary primary incisors were recalled for a
follow-up examination of the erupted permanent successors. The children had a total of 118 intruded teeth.
The severity of intrusion was recorded as well as the developmental stage of the permanent successor and
the treatment given at the time of trauma. The permanent successors were examined for different levels of
developmental disturbances. Results Seventy per cent of the succeeding incisors had some complications in
development. White or yellow-brown hypomineralisation was the most common finding representing 60%
of all complications. The more serious complications such as circular hypoplasia, crown dilaceration,
odontoma-like malformation, root developmental disturbances, sequestration of the tooth germ, and
eruption disturbances were few and the majority (90%) related to trauma before the age of 3 years
combined with severe intrusion. When the intruded primary incisor was extracted, 80% of the permanent
successors developed complications. Conclusions Traumatic injuries to primary incisors are common.
Because of the close relationship between the apices of the primary incisors and developing permanent teeth,
disturbances in development occur. Intrusion of a primary incisor often occurs before the age of 3 years and
the risks of damage occurring to the permanent germ are high.

KEY WORDS: Trauma, Intrusion, Primary teeth, Sequelae

Introduction 1995, Diab and El Badrawy, 2000].

Epidemiologic studies indicate that about 30%
of all children traumatize one or more of their
primary incisors [Andreasen and Ravn, 1972;
Andreasen, 1985, 1994].
Intrusive luxation injuries to primary incisors are
a common trauma, especially in children up to the
age of 3 years [Ravn, 1968; Selliseth, 1970;
Andreasen and Ravn, 1972; Haavikko and
Rantanen, 1976; Borum, 1994]. Developmental
disturbances of permanent successors are often
seen as a result of the intrusion of primary incisors
[Andreasen and Ravn, 1971; Ravn, 1976; Brin et
al., 1984; Ben-Bassat et al., 1985; von Arx, 1993,
*Department of Pedodontics, Faculty of Odontology,
Göteborg University and Public Dental Service, Göteborg, Sweden
**Department of Paediatric Dentistry,
The Institute for Postgraduate Dental Education, Jönköping, Sweden
The close relationship between the apices of the
primary teeth and the developing permanent
successors explains the high prevalence of
disturbances. There are a number of reports on
different luxation injuries to primary teeth and
their effect on the permanent successor. However,
most of the materials presented are small, and the
frequency of disturbances in permanent teeth
differs considerably. This is particularly true
concerning intrusive luxation injuries to primary
teeth. The reasons for this might be that the
material in studies on intrusion varies in respect of
clinical examination at the time of trauma, e.g.
registration of degree of intrusion, age of the child,
developmental stage of the permanent tooth
germ, and treatment.
The aim of the present study was therefore to
report the frequency of developmental
disturbances in permanent teeth as a result of

EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 4/2001 165

M. L. ODERSJÖ, G. KOCH
intrusive injuries to the primary predecessors and
relate this to the degree of intrusion, the age of the
child, the developmental stage of permanent tooth
germ and the treatment given. Knowledge of
factors influencing the frequency and severity of
complications are important in the prediction of
disturbances resulting from trauma.
Materials and methods
In this study were included all children who had
been referred to the Department of Paediatric
Dentistry, The Institute for Postgraduate Dental
Education, Jönköping, Sweden (IPGDE), because
of trauma resulting in the intrusion of a primary
incisor were at least 8 years old at the time of the
study, and had fully erupted permanent maxillary
central incisors. With one exception, children who
had undergone more than one traumatic incident
were excluded.
The study population, therefore, consisted of 95
children who had experienced a traumatic
intrusion of a primary incisor between 1973 and
1997. Most of the trauma had happened by falling
against the ground or furniture while playing.
Only few trauma were caused by traffic accidents.
The children had been given emergency treatment
at IPGDE and the more detailed treatment was
pending. Improved oral hygiene and
abandonment of the use of pacifiers was advised.
Antibiotics were seldom prescribed. Radiographs
were available from the time of the trauma for all
the children. They all had been followed up,
clinically and radiographically, for several years
depending on healing and treatment.
All 95 children were called for a follow-up
examination of any sequelae in the permanent
successors because of the intrusive trauma of their
primary incisors. Fifteen of the children had
moved from the area and 10 declined to
participate.
Thus 70 children (29 girls and 41 boys) with a
total of 118 intruded teeth (38 had one intruded
tooth, 23 had two teeth, 2 had three teeth, and 7
had four teeth) were examined by one of the
authors (MLO) concerning their permanent
incisors (Table 1). One boy who had been exposed
to intrusive trauma on two occasions but which
involved different teeth was included. The follow-
up included both a clinical and a photographic
examination. Prior to this clinical examination, all
recent radiographs of the maxillary incisor region
were requested from the Public Dental Service
166
that was now caring for each child. At the follow-
up examination and from previous dental records,
the following information [modified from
Andreasen and Ravn 1971; von Arx 1995] was
collected.
- Sex.
- Age at the time of trauma (registered at 1-year
intervals, e.g. in the tables, ‘2-3 years’ means that
the child had reached the age of 2 years but not
yet turned 3).
- The tooth or teeth that were traumatized.
- The developmental stage of the permanent
successor at the time of trauma as:
mineralization of the incisal part;
mineralization of about half of the crown;
mineralization of the entire crown.
- The degree of intrusion of the primary incisors
at the time of trauma:
less than half of the crown was intruded;
half or more of the crown was intruded;
all of the crown was intruded (complete).
- Treatment given to the intruded incisor at the
time of trauma and later:
- no extraction
re-eruption without complications,
re-eruption with mild complications
(obliteration or colour changes with no
radiographically verified signs of periapical
infection);
- extraction of the intruded incisor
immediately (within 1 week),
later because of complications (pulp necrosis
with radiographically verified signs of
periapical infection, long-lasting mobility in
combination with periapical infection,
anchylosis, or fistula).
- Complications in the erupted permanent
successor (a tooth can show more than one
complication):
white or yellow-brown enamel hypo-
mineralisation;
localised enamel hypoplasia;
hypomineralisation and circular enamel
hypoplasia;
crown dilaceration;
odontoma-like malformation;
disturbed root development;
sequestered tooth germ;
disturbed eruption;
no changes.
These different outcomes are illustrated in
figures 1-5.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 4/2001
 PRIMARY TEETH INTRUSION

FIG. 1 - Boy 2.5 years at

the time of trauma.
a: half of the crown 61
intruded. b: white enamel
a hypomineralisation. b

FIG. 2 - Boy 2.5 years at

the time of trauma.
a: complete intrusion 61.
Half of the crown 21
mineralised. Observe the
close contact with the apex
of 61 and 22.
b: white enamel hypomin-
eralization and localised
a enamel hypoplasia 21, 22. b

a b c
FIG. 3 - Girl 1.7 years at the time of trauma. a: complete intrusion 61. Half of the crown 21 mineralised.
b and c: radiograph and clinical picture of hypomineralisation and circular enamel hypoplasia.

a b c
FIG. 4 - Girl 1.7 years at the time of trauma. Complete intrusion. a: radiograph at 3.7 years of age. No re-eruption.
Later extraction. b and c: radiograph and clinical picture of hypomineralisation and crown dilaceration 21.

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M. L. ODERSJÖ, G. KOCH

a b c
FIG. 5 - Girl 9 months at the time of trauma. All primary maxillary incisors intruded to half of the crown. a: radiograph
3 months after trauma. 51 inflammatory apical resorption and tooth germ 11 incisal part mineralised and malformed.
b: radiograph at 5 years of age. Note odontoma-like malformation of crown 11, tendency to pre-eruption and early root
formation. c: radiograph at 7.5 years of age. Note the rapid development of the root 11.

Results trauma in 79 teeth as: incisal part mineralised 11

More than 85% of the intrusive accidents (14%); mineralisation of half of the crown 48
occurred before the age of 3 years (Table 1). (61%) and mineralisation of the entire crown 20
Among the 118 traumatized primary maxillary (25%). For the rest of the permanent successor
incisors, the tooth that was most frequently teeth, the radiographs gave no clear-cut
intruded was the central incisor. information. At the time of trauma, 75% of the
The distribution between left and right central permanent successors had not reached the
incisors was equal, 46 of each. developmental stage where the entire crown was
It was possible to register the developmental mineralised. Nine teeth had been extracted within
stage of the permanent successor at the time of one week, and 109 had been left for re-eruption.
Thirty-four teeth had to be extracted later because
of complications such as pulp necrosis, resorption,
and absence of re-eruption. Thus the success rate
for the 109 teeth left for re-eruption was 69%. The
Child’s age* N. intruded teeth N. childr.
distribution according to treatment of 118 teeth
at trauma (%) (%)
was divided into the no extraction group, of which
0–1 13 (11) 5 (7)
65 (55%) erupted without complications and 10
(8%) erupted with mild complications, and the
1–2 39 (33) 28 (39)**
extraction group, where 9 (8%) were extracted
2–3 53 (45) 29 (41) immediately (within one week) and 34 (29%)
3–4 7 (6) 6 (9) needed a later extraction. About 70% of all
4–5 5 (4) 2 (3)** permanent successor teeth in children with
5–6 1 (1) 1 (1)
intruded primary incisors developed
complications (Table 2). The most commonly
118 70** found disturbance was white or yellow-brown
enamel hypomineralisation, which represented
* Registered at 1-year intervals e.g. ‘2-3 years’ means that the
child has reached the age of 2 years but not yet turned 3 59% of all disturbances, followed by localised
** Intrusive trauma had occurred to one child on two separate hypoplasia (27%). The other changes were few.
occasions and affected different teeth The seven teeth with the most serious
complications were found in four children who
TABLE 1 - Intruded primary incisors distributed accor- had intrusion of half the crown or more and whose
ding to age at the time of trauma. mean age at the time of trauma was 1.5 years.

168 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 4/2001

 PRIMARY TEETH INTRUSION

Complications Age in years at the time of trauma Total compl.

0-1 1-2 2-3 3-4 4-5 5-6 (%)

White or yellow-brown enamel hypomin. 3 13 28 0 4 1 49 (59)

Localized enamel hypoplasia 4 8 6 3 1 0 22 (27)
Hypomin. + circular enamel hypoplasia 3 7 4 0 0 0 14 (17)
Crown dilaceration 1 1 1 0 0 0 3 (4)
Odontoma-like malformation 0 1 0 0 0 0 1 (1)
Disturbed root development 0 0 1 0 0 0 1 (1)
Sequestered tooth germ 0 0 0 0 0 0 0 (0)
Disturbed eruption 0 1 1 0 0 0 2 (2)

Number and percentage (in brackets)

of teeth with complications 9 (69) 28 (72) 37 (70) 3 (43) 5 (100) 1 (100) 83 (70)

TABLE 2 - Complications in permanent successors distributed according to age at the time of trauma (a tooth can show
several complications).

Complications Degree of intrusion Developmental stage-mineralized

<1/2 crown 1/2 or more Complete Incisal part 1/2 crown Entire crown

White or yellow-brown enamel hypomin. 24 10 15 5 21 9

Localized enamel hypoplasia 13 6 3 3 6 6
Hypomin. + circular enamel hypoplasia 2 2 10 1 6 1
Crown dilaceration 0 1 2 0 1 0
Odontoma-like malformation 0 1 0 1 0 0
Disturbed root development 0 0 1 0 1 0
Sequestered tooth germ 0 0 0 0 0 0
Disturbed eruption 0 1 1 1 1 0

Number and percentage (in brackets)

of teeth with complications 37 (79) 18 (62) 28 (67) 9 (82) 33 (69) 15 (75)

TABLE 3 - Complications in permanent successors distributed according to the degree of intrusion of the primary incisor
and the developmental stage of the permanent tooth at the time of trauma.

Eleven (16%) intruded primary central incisors
were the source not only of a complication on a
permanent central incisor but also a
developmental disturbance on a permanent lateral
incisor. The distribution of complications in
permanent successors is presented in Tables 2-5. It
was found that the same tooth could have more
than one complication. Thus one tooth had three
complications and seven teeth had two
complications each. Most were
hypomineralisations or localised hypoplasias,
while severe disturbances such as crown
dilaceration and odontoma-like malformations
were few (Table 2).
About 60% of the primary teeth showed a degree
of intrusion of more than half the crown and 35%
had crowns that were completely intruded. The
effect of the degree of intrusion of the primary
tooth on complications in the permanent
successors is presented in Table 3. When less than
half the crown of the primary incisor was intruded,
approximately 80% of the successor teeth
developed complications. When the primary incisor
was completely intruded, approximately 70% of
the successor teeth developed complications. The
most serious, such as crown dilaceration,
odontoma-like malformations, and root
developmental disturbances, were found only when

EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 4/2001 169

M. L. ODERSJÖ, G. KOCH

half or more of the crown was intruded (Table 3).
Irrespective of the developmental stage of the
permanent tooth at the time of trauma, about 75%
of the teeth had complications. The more serious
complications were found when the trauma had
occurred before the entire crown of the permanent
successor was mineralised (Table 3).
In 19 of the 21 teeth that had severe
complications (hypomineralization and circular
enamel hypoplasia or worse), intrusion was half or
more of the crown and had occurred when the
child was under the age of 3 years (Table 2, 4).
In Table 5 it can be seen that a higher percentage
of permanent successors had complications in
those children where the intruded incisor had been
extracted immediately or later. About 80% of the
extraction cases developed complications in the
permanent successor compared with about 65% in
the no extraction group. Almost all the serious
complications were found in the late extraction
group.
Discussion
The present study is retrospective, descriptive in
nature. The rather small subgroups within the
material did not allow us to perform meaningful
statistical analysis on differences between the
groups. When analysing the results it must also be
remembered that the patients in the present study

Complications Age at trauma (yrs) Total complications

0–1 1–2 2–3

White or yellow-brown enamel hypomin. 1 4 19 24

Localized enamel hypoplasia
Hypomin. + circular enamel hypoplasia
Crown dilaceration
Odontoma-like malformation
Disturbed root development
Sequestered tooth germ
Disturbed eruption
1 2 4 7
4 6 2 12
1 1 1 3
0 1 0 1
0 0 1 1
0 0 0 0
0 1 1 2

No changes 4 7 10

TABLE 4 - Complications in permanent successors according to intrusion of half or more of the primary tooth crown and
age below 3 years at the time of trauma.

Complications in permanent teeth No extraction Extraction

RE-ERUPTION Immediately Later
no complications mild complications (within a week)

White or yellow-brown enamel hypomin. 25 3 4 17

Localized enamel hypoplasia 12 2 2 6
Hypomin. + circular enamel hypoplasia 7 1 1 5
Crown dilaceration 0 0 0 3
Odontoma-like malformation 1 0 0 0
Disturbed root development 0 0 0 1
Sequestered tooth germ 0 0 0 0
Disturbed eruption 1 0 0 1
Number and percentage (in brackets)
of teeth with complications 42 (65) 6 (60) 7 (78) 28 (82)

TABLE 5 - Complications in permanent successors distributed according to treatment and follow-up of primary incisor.

170 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 4/2001


had been referred to a specialist clinic in paediatric
dentistry. Our study might therefore represent
more severe intrusions and younger patients
compared with those from general dental practice.
The frequency of complications could therefore be
expected to be somewhat higher than in a less
selected material.
An analysis of the dropouts at the time of trauma
revealed a distribution of age and degree of
intrusion equal to those in the material studied.
They could thus not have influenced the outcome
of the present study.
The high frequency of complications in
permanent successor teeth in the present study is
in accordance with findings presented by
Andreasen and Ravn [1971] and Selliseth [1970].
In other studies [Ravn, 1976; Brin et al., 1984; von
Arx, 1995], a somewhat lower frequency of
complications caused by the intrusion of primary
incisors, between 45% and 60%, has been
reported. Possible explanations for this might be
differences in the criteria used to diagnose the
complications, the age distribution of the children
at the time of trauma, and the severity of the
trauma. The ratio of boys to girls in this study was
1.4:1, which is similar to the ratios presented by
other authors [Andreasen and Ravn, 1971;
Selliseth, 1970].
Compared with Ravn [1976], who found
complications in 54% of the intruded teeth and
intrusion of more than one tooth in 24% of the
children, we found 70% and 45% respectively in
the present study. The present study also included
a higher percentage of children under the age of 1
year. This study thus has both cases that had
undergone more severe trauma and younger
individuals, which might explain the difference in
frequency of complications.
It is important to observe that in the present
study, as in other similar ones [Andreasen and
Ravn, 1971; von Arx, 1995; Ben-Bassat et al., 1989;
Brin et al., 1984], the most frequent complications
were mild, for example white or yellow-brown
enamel hypomineralisations. These accounted for
more than 50% of cases. Severe disturbances such
as hypomineralisation and circular enamel
hypoplasia, crown dilaceration, and odontoma-like
malformations seem to occur only when the child
is under 3 years of age at the time of trauma and
when at least half or more of the primary crown is
intruded. Severe complications might be expected
in 90% of such cases. This is also in line with results
presented by Ravn [1976], Ben-Bassat [1985],
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 4/2001
PRIMARY TEETH INTRUSION
Zilberman et al. [1986], and von Arx [1995] who
stressed that if the intrusion is severe and if the
successor is in an early developmental stage, the
risk of complications is higher.
Complications to the permanent lateral incisors
(16%) after intrusion of the primary central
incisor were high and unexpected. However, this
had been observed by von Arx [1995] and a
thorough analysis of the radiographs of the
present study revealed that the intruded root apex
was often very close to the location of the
hypoplasia after the permanent lateral incisor had
erupted (Fig. 2).
The influence of treatment of the intruded
primary incisors on complications in permanent
successors has been discussed by several authors
[Selliseth, 1970; Andreasen and Ravn, 1971; Ravn,
1976; von Arx, 1995]. The frequency of
complications in the permanent successors was
more pronounced if the primary incisors had been
extracted (about 80%) compared with the non-
extraction cases (about 60%). These findings are in
agreement with von Arx [1995] and supported by
Ravn [1976] but differ slightly from Selliseth
[1970]. It might be expected that the extraction
cases represented more severe trauma and that a
combination of infection and pulp necrosis might
increase the risk of complications. However, there
seems to be no clear rationale to extract intruded
primary incisors immediately. Retrospective
studies on traumatic injuries to the teeth covering
periods of several years have a natural built-in
weakness. In the future, therefore, it is important
that studies focus on evaluating the effects of
trauma in a prospective way. Such a study is in
process and it will also cover the epidemiology of
trauma to the primary teeth in a non-selected child
population.
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