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Received: 11 October 2020    Revised: 15 January 2021    Accepted: 16 January 2021

DOI: 10.1111/edt.12665

CASE REPORT

Multiple abnormalities in permanent incisors diagnosed six

years after a severe intrusive injury in the primary dentition: A
case report

Farah Chouchene  | Rihab Mabrouk  | Fatma Masmoudi | Ahlem Baaziz |

Fethi Maatouk | Hichem Ghedira

Pediatric and Preventive Dentistry

Department, Faculty of Dental Medicine
of Monastir, Laboratory of Biological,
Clinical and Dento-­Facial Approach,
University of Monastir, Monastir, Tunisia
Correspondence
Farah Chouchene, Pediatric and
Preventive Dentistry Department, Faculty
of Dental Medicine of Monastir, Biological
Approach and Dento-­Facial Clinic
Laboratory, Monastir, Tunisia.
Email: farah.pedo@gmail.com
Abstract
Severe intrusion injuries of primary teeth are frequently associated with serious de-
velopmental disorders. This report describes the diagnostic procedures and the mul-
tidisciplinary approach for multiple sequelae to permanent incisors due to a severe
intrusive injury of the primary maxillary anterior teeth at the age of 18 months in a
7-­year-­old girl. Clinical examination revealed hypoplasia of tooth 22, and radiographic
examination showed crown-­root malformation of tooth 21, impaction of tooth 11,
and the presence of an odontoma-­like malformation on tooth 12. The affected tooth
12 had a poor prognosis, as highlighted by CBCT, and it was extracted. While for the
impacted 11, a surgical extraction followed by an orthodontic treatment is scheduled.
Aesthetic and functional problems were solved by a functional space maintainer using
a removable partial denture.
The occurrence of multiple abnormalities in permanent teeth as a result of intrusive
injuries in the primary dentition enhances the need for creating awareness among
dentists not only of the importance of appropriate immediate management of trauma
but also of the importance of establishing a long-­term follow up and subsequent man-
agement of any sequelae.

KEYWORDS
enamel hypoplasia, intrusion, odontoma-­like malformation, primary teeth, sequelae of trauma,
traumatic injuries

1  |  I NTRO D U C TI O N 30%.1-­5 Intrusion comprises 8-­54% of all luxation injuries of primary

Trauma of the oral hard and soft tissues is very common in young
children.1 Epidemiological studies have reported that approximately
one-­third of children and one-­quarter of adolescents and adults
have experienced dental trauma, and most of these injuries involved
2
the upper central incisors.
The reported prevalence of traumatic injuries in the primary den-
tition varies among different studies and ranges between 11% and
anterior teeth.1,3,6
Due to the close proximity of the developing permanent suc-
cessor and the roots of the primary teeth, intrusion in the primary
dentition may present a significant risk of sequelae in the permanent
teeth.7
After a traumatic injury to the primary dentition, the sequelae
in permanent teeth are closely related not only to the type of injury,
but also to the severity of the injury, the age of the child at the time

© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Dental Traumatology. 2021;00:1–6.  |

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2      CHOUCHENE et al.
of the trauma, and any association with other factors such as alveo-
5,8-­10
lar bone fractures.
The sequelae could manifest as various pathological changes
such as hypoplasia (enamel discoloration and/or enamel defects),
crown dilaceration, root angulation or dilaceration, partial or com-
plete arrest of root formation, permanent tooth germ sequestration,
odontoma-­like malformation, and disturbances of eruption (ectopic
or lack of re-­eruption).11-­13 These changes may cause different clin-
ical problems such as malocclusions, dental problems, periodontal
problems, and unaesthetic appearance which explain the need for
multidisciplinary approach and long-­term follow ups.
This report describes the diagnostic procedures and the multi-
disciplinary approach for a seven-­year-­old girl with multiple abnor-
malities of her permanent incisors following intrusion in the primary
dentition.
2  |  C A S E R E P O RT
The present case report was prepared according to the CARE (CAse
REport) Guidelines.14
A 7-­year-­old female patient was referred to the Pediatric
Dentistry Department of the School of Dentistry of Monastir from
a general dentist for investigation of unerupted maxillary incisors.
The general dentist had initially referred the patient to a specialist pe-
diatric dentist 12 months prior. However due to the patient's family eco-
nomic status, presentation to a specialist pediatric dentist was delayed.
Written informed consent was provided by the child's father for
all examination and treatment procedures.
The medical history of the patient showed no specific problems
and the child was in good general health. Upon extra-­oral examina-
tion, no abnormalities were detected.
Intraoral examination showed a lack of teeth 12, 11, and 21 and
an erupted tooth 22 with a hypoplastic crown (Figure 1).
During the clinical interview, the parents reported that, at the
age of 18 months, the child had sustained a severe traumatic injury
to the primary maxillary anterior teeth after a fall from the stairs.
The parents could not recall all the details but confirmed that the
anterior incisors were fully intruded (completely displaced into the
alveolar bone). No radiographic examination had been carried out at
(A) (B)
F I G U R E 1  Intraoral views showing lack of teeth #12, #11, #21, and discolored tooth #22
that time. The parents reported also that the teeth re-­erupted seven
months later but no dental follow up was arranged.
The patient had not been seen by any dentist until one year be-
fore her visit to the Pediatric Dentistry Department.
An orthopantomogram taken one year before the day of con-
sultation showed that the upper right lateral incisor (12) had a ra-
diopaque tooth-­like tissue, tooth 11 was noted in a more cranial
position compared with its contralateral counterpart (tooth 21), and
tooth 21 had an irregular crown morphology (Figure 2).
A more recent orthopantomograph was requested and showed
that the root formation of teeth 21 and 22 was almost completed.
An odontoma-­like malformation of tooth 12 and tooth 11 was
horizontally displaced and impacted. However, it was not possible
to exactly define the root apex on the conventional radiograph
(Figure 3).
A CBCT was then performed and showed marked proclination
and subocclusal position with anomalous crown morphology of
tooth 11 and an impacted radiopaque calcified mass resembling
an odontoma-­like malformation in place of tooth 12 (Figures 4
and 5).
Since the child's major concern was being ridiculed at school
for her appearance, the initial management involved restoration of
the crown abnormality of the 22 with composite resin (3 M™ Filtek
Supreme XTE universal restorative), improvement of the esthetics,
11
21
12
22
F I G U R E 2  Orthopantomograph showing abnormal morphology
in teeth #21, #22, #12, and impacted tooth #11
(C)
CHOUCHENE et al. |
      3

and correction of functions, especially phonation and swallowing by Considering the poor prognosis of the affected tooth 12 which
making a functional space maintainer using a removable partial den- was highlighted by the CBCT, a treatment plan including its surgi-
ture (Figure 6). cal extraction was programmed, but the patient did not attend the
scheduled appointment.
The patient presented again, 12 months later, with tooth 21 now
11
21 erupted and presenting an irregular crown morphology. Surgical
22
extraction of tooth 12 under conscious sedation was performed.
The extracted tooth had multiple abnormalities, including enamel
12 hypoplasia, root dilaceration, and root duplication (Figure 7).
For tooth 21 with coronal abnormality, a coronal restoration
was considered in collaboration with the Prosthetic Department,
while for the impacted tooth 11, in collaboration with the
Department of Orthodontics, the following treatment plan was
considered: surgical extraction followed by orthodontic treatment
F I G U R E 3  Orthopantomograph showing impacted tooth #11
and evolution of the root formation of the teeth #21 and #22 to keep the space open until definitive prosthodontic treatments
can be performed.

F I G U R E 4  Multiplanar reformatted (MPR) and 3D image. Altered crown morphology in tooth 12 is seen in the coronal view (top left).
Palatal dilacerations of crown and aberrant pulp chamber are noted in tooth 11 in the sagittal view (top right). 3D images (bottom right) show
the position of tooth 11
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4      CHOUCHENE et al.

F I G U R E 5  Multiplanar-­reformatted (MPR) and volume-­rendered (VR) image show impacted radiopaque calcified mass resembling
odontoma-­like malformation in place of tooth 12 (coronal view top right)

3  |  D I S C U S S I O N

The occurrence of developmental anomalies in permanent incisors

that can be attributed to injuries of their predecessors ranges from
12 to 74%.8,15-­17 Intrusive injuries are the most common and seri-
ous type of trauma in the primary dentition. These injuries require
a careful examination by the dentist not only of the damaged tooth,
but also monitoring for the possible sequelae of the permanent
tooth.11,18,19
According to previous guidelines, the treatment of intrusive in-
juries in the primary dentition depends mainly on determining the
relationship between the root(s) of the primary tooth and the tooth
germ of the permanent tooth. 20 More recent guidelines21 state that
the tooth should be allowed to spontaneously reposition itself, ir-
respective of the direction of displacement and regular clinical
and radiographic follow-­ups should be performed during the first
12 months after the trauma. Further follow-­up at 6 years of age is F I G U R E 6  Intraoral view after aesthetic rehabilitation of the
indicated for severe intrusion. patient
CHOUCHENE et al.
F I G U R E 7  A, the extracted tooth 12
(A)
and B, the clinical appearance following
extraction
In the present case report, the lack of both regular follow-­up
and pre-­eruptive radiography complicated the management of this
patient. This emphasizes the importance of regular follow-­up ap-
pointments and pre-­eruptive radiography in the early detection and
treatment of possible severe development disorders in the perma-
nent teeth. The importance of accurate examination and documen-
tation is evident in traumatic injuries, especially in children aged
between one and three years, and regular-­follow ups are particularly
20
recommended.
The developmental disturbances are more severe and more fre-
quent when the traumatic injuries occur at younger ages (< 2 years old)
due to the incomplete bone formation and permanent tooth mineral-
ization.9 This report describes multiple sequalae of permanent incisors
due to severe intrusive injuries of the maxillary anterior primary teeth
at a very young age (18 months). The rarity of this case can be under-
lined by the simultaneous occurrence of several types of severe dental
anomalies in the same dental arch, after the same traumatic episode.
As a result of traumatic injury to the primary dentition, the de-
velopment of an odontoma usually occurs at a very young age when
the maxillary bone height is small. 22 These malformations should
be removed surgically at a suitable time. 23 In the present case, the
malformation was detected 6 years after the trauma. However, its
extraction was delayed due to the patient's conditions. Other possi-
ble outcomes following traumatic injuries to their predecessors are
the eruption failure or delay, ectopic eruption, or impaction of the
permanent teeth.15,16,24
These disturbances may result from the physical displacement of
the permanent tooth germ, the abnormal changes that might occur
in the connective tissue and the lack of eruption guidance from the
prematurely lost primary incisor.15 In the current case, not only an
odontoma-­like malformation of tooth 12 occurred, but tooth 11 also
had delayed eruption due to its impaction.
Such situations generally imply the need for advanced imaging
techniques rather than conventional radiographs. Imaging modali-
ties such as CBCT can result in better diagnosis and more efficient
management of complex malformations. 2 Three-­dimensional images
enable analysis of the precise location and orientation of the im-
pacted tooth. 26
|
      5
(B)
Clinical signs of an impacted tooth include asymmetric eruption of
more than 6 months in relation to its homologue, retention of the pri-
mary tooth, change in the chronology and sequence of normal erup-
tion, mid-­line deviation, space closure, and elevation of the soft tissue
of the palatal and labial mucosa.26-­28 Impaction and alteration in tooth
morphology represent a clinical challenge with regard to diagnosis,
treatment planning, and prognosis. The treatment of this type of se-
quelae may require the following: surgical, endodontic or aesthetic
procedures, and orthodontics with the need of specialists from dif-
ferent fields of dentistry, resulting in lengthy treatment. Depending
on the degree of dilacerations and the localization of the tooth, dif-
ferent treatment options have been suggested in the literature.27
In the present case report, a functional space maintainer using a
removable partial prosthesis was provided and the patient was very
satisfied with the prosthesis. Although the treatment was consid-
ered temporary, it has improved the aesthetics and the psychologi-
cal outlook of the child, increased her self-­confidence, and corrected
her speech, chewing, and swallowing.
In many cases, the sequelae in permanent teeth resulting from
traumatic injuries need a multidisciplinary clinical approach and de-
layed treatment will require more complex interventions. Prompt
treatment planning and early diagnosis can lead to successful out-
comes, and dentists play an important role in educating patients and
parents regarding traumatic injuries and their sequelae. 29,30
AC K N OW L E D G M E N T S
The patient management has been carried out at the Pediatric
and Preventive Dentistry Department at the Faculty of Dental
Medicine of Monastir. The authors report no declarations of
interest.
C O N FL I C T O F I N T E R E S T
None of the authors has declared any conflict of interest or financial
disclosures.
ORCID
Farah Chouchene  https://orcid.org/0000-0003-0256-913X
Rihab Mabrouk  https://orcid.org/0000-0001-8989-3498
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6      CHOUCHENE et al.
18. Kargul B, Çağlar E, Tanboga I. Dental trauma in Turkish children.
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How to cite this article: Chouchene F, Mabrouk R, Masmoudi F,
Baaziz A, Maatouk F, Ghedira H. Multiple abnormalities in
permanent incisors diagnosed six years after a severe intrusive
injury in the primary dentition: A case report. Dental
Traumatology. 2021;00:1–6. https://doi.org/10.1111/edt.12665