Paediatric Dentistry

Enhanced CPD DO C

Kirstie Lau

Shruti Patel, Cathy Bryant and Sanjeev Sood

Sequelae of Primary Dental

Trauma: A Case Series
Abstract: Trauma to the primary dentition is a common occurrence affecting approximately 1 in 5 young children globally. Damage
to the successor tooth may present as a localized enamel defect, dilaceration and disturbed eruption, with subsequent functional and
social impact. Appropriate management of acute primary dental trauma, regular review and timely specialist referral upon detection
of eruption sequence abnormalities is, therefore, imperative for long-term outcome to be optimal. This article presents a series of four
case reports of paediatric patients with a history of severe primary dental trauma that resulted in significant dental anomalies requiring
multidisciplinary treatment.
CPD/Clinical Relevance: Information on the consequences of primary dental trauma and the advice to give to affected families is of value.
Dent Update 2024; 51: 12–20

Trauma to the primary dentition to its successor’s developing tooth germ The acute management of primary
is a common occurrence affecting (Table 1). The severity of the developmental dental trauma often requires long-term
approximately 1 in 5 young children disturbance to the permanent tooth reflects active monitoring and assessment of
globally.1 In addition to the initial physical the type of trauma sustained, the force of indicators of treatment need. As primary
injury to the child, the unerupted, impact, and the child’s age and stage of and secondary teeth are often separated by
developing permanent dentition may also dental development. Mild luxation, extrusion only a few millimetres of fibrous connective
be impacted to varying degrees of severity. or crown fracture injuries to the primary tissue, the extraction of a traumatized
This case series describes the sequelae tooth may result in white-yellow or brown primary tooth has the potential to further
of primary trauma, its diagnosis and enamel discolouration and hypoplasia of the traumatize its successor. Intrusive luxation
management, therefore enabling delivery permanent successor, while severe dental is considered the most damaging primary
of advice and expectation management for trauma such as avulsion, intrusion and dental injury, hence current dental trauma
paediatric patients and their families. alveolar trauma are likely to be associated guidelines recommend intervention only
Damage to the developing permanent with more significant dental abnormality when signs of pulpal necrosis are evident.5
dentition following primary dental trauma including crown or root dilaceration, This is due to evidence that intruded primary
is uncommon, but arises owing to the sequestration of successor tooth germs and teeth have a tendency to spontaneously
close proximity of the primary tooth apex disturbances in eruption.2 re-erupt, and also due to a lack of evidence
that their immediate extraction minimizes
further damage to the successor tooth germ.
In clinical practice, intervention for primary
Kirstie Lau, BDS, MFDSRCS, MSc, MPaedRCS,, Specialty Registrar in Paediatric Dentistry,
trauma is indicated in only a minority of
Department of Paediatric Dentistry, King’s College Hospital NHS Foundation Trust,
patients. Holan demonstrated that only 25%
London. Shruti Patel, BDS, FDSRCS, MSc, MOrthoRCS, FDSOrthRCS, Consultant in
of traumatized primary teeth devitalized
Orthodontics, Department of Orthodontics, King’s College Hospital NHS Foundation
(developed an associated sinus or swelling)
Trust, London. Cathy Bryant, BDS, FDSRCS, MSc Consultant in Oral Surgery, Department
within a 5-year follow up.6
of Oral Surgery, King’s College Hospital NHS Foundation Trust, London. Sanjeev Sood,
It is recommended that children with
BDS, MFDSRCS, MDentCh, FDSRCS, Consultant in Paediatric Dentistry, Department of
primary trauma are reviewed until the
Paediatric Dentistry, King’s College Hospital NHS Foundation Trust, London.
eruption of the successor secondary tooth.5
email: kirstie.lau@nhslothian.scot.nhs.uk
Crown formation of the permanent incisors

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 Paediatric Dentistry

Complication Definition Aetiology Incidence (out of

all primary dental
trauma sequelae)

No – – 71%4
complications
Disturbances Delayed or premature Injury to connective 12–69%3
in eruption eruption of the successor tissue overlying
tooth the tooth germ
during development
Enamel Quantitative enamel Injury during 12–23%3
hypoplasia defect, can present as pits, enamel
grooves and white-yellow maturation stage Figure 1. Development of permanent maxillary
or brown discolouration and mandibular incisors’ crown and root, and the
corresponding ages of completion.
Dilaceration Deviation or angulation to Non-axial injury <3%3
the long axis of the root displacement during
or crown hard tissue tooth
germ development department is essential in optimising
Root Traumatic division of Severe intrusion <1%3 patient outcomes.
duplication the root resulting in the injury during the The following case reports showcase
formation of two roots root formation stage four paediatric patients who presented with
a range of anomalies in their permanent
Odontoma- Mass of mineralized Severe trauma to <1%3 dentition following primary dental trauma.
like tissue of enamel, dentine, the developing Their referral to secondary care and
malformation cementum and pulp tooth germ subsequent management is described in
Table 1. Sequelae following primary dental trauma, based on Andreasen et al3 and Lenzi et al.4 order to inform the reader about what can
be expected after such a referral is made,
Age (years) Incidence per 1000 of so that this information can be shared
traumatic dental injury with patients and their families. Features
child’s teeth is essential and it is the role of
such as a history of severe primary dental
0–3 51.8 the dentist to educate parents to prioritize
trauma, multiple complex developmental
regular trauma follow up. Delivering
4–5 38.6 anomalies of the permanent dentition and
appropriate advice to the affected families
the burden of completing and maintaining
6–7 32.1 is essential in ensuring trauma review
dental treatment into adulthood are
Table 2. Incidence of traumatic dental injury in attendance, identification of pulpal necrosis
common to all the patients described, and
different age groups based on Glendor et al.7 symptoms and prevention of repeat
are shared themes in patients with this
trauma. For instance, increased overjet, and
history.12 Clinicians may find parents are
associated digit sucking habits, are high
unable to report on the type of primary
risk of trauma to primary and permanent
begins at age 7 months and continues trauma their child experienced many years
maxillary incisors, thus cessation advice is
to 5 years. Incidence of dental trauma ago. Hence as part of history taking, the
recommended as part of management in
clinician can ask if the nature of the injury
is increased during this age range, and general dental care.8–10
resulted in movement of the tooth or a
is linked with poor muscle coordination The majority of enamel defects
break in the tooth to determine whether
of young children learning to walk and affecting permanent incisors that
it was a luxative or fracture injury, and
play (Table 2). Therefore, dental trauma develop as a consequence of trauma
therefore gain insight on its likely long-
within this age range carries an increased to the preceding primary dentition can
term prognosis. For each case, the authors
risk and complexity of damage to the be managed in general dental practice. provide learning points that can be applied
permanent incisors. This would most frequently involve by clinicians working in both primary and
General dental practitioners (GDPs) restoration of enamel hypoplasia as part secondary care settings.
are often the first to identify and diagnose of level 1 care.11 In that regard, specialist
complications arising from primary dental management of complications in the
trauma. Earlier primary dental trauma permanent dentition following primary Case 1: Enamel hypoplasia
can often be forgotten by parents and trauma may be indicated as part of level 3 Enamel defects can occur following
it is not until an anomalous permanent care for multidisciplinary input, or for disruption to amelogenesis in the late
successor erupts, or the eruption of the management of dental development secretory or early maturation phase of
permanent tooth is delayed or fails, that abnormalities not amenable to simple dental development. Trauma to the tooth
complications from the primary trauma preventive or restorative treatment.11 germ during this window of development
are recognized. Following dental trauma, Therefore timely referral to their local can result in defects in the enamel, such as
parental involvement in monitoring their hospital orthodontic or paediatric dentistry hypoplasia or hypomineralization. Enamel

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 Paediatric Dentistry
a a
Figure 2. Comparison of hypoplasia and
hypomineralization. (a) Clinical photograph
showing chronological hypoplasia. (b) Clinical
photograph showing molar–incisor
hypomineralization of the incisors and tips
of canines.
hypoplasia is a defect in the quantity
of enamel, presenting as white-yellow-
brown discolouration and sensitivity,
and radiographically as transverse
radiolucent lines. This is distinguished from
hypomineralization, which is a defect in the
enamel quality resulting in discolouration,
sensitivity, reduced bonding strength
to resin restorations and radiographic
presentation of blurred enamel and dentine
radiodensities (Figure 2). 13,14
Enamel hypoplasia is one of the most
common sequelae of primary dental
trauma, affecting 12–23% of permanent
teeth,2,3 and most likely to be the result
of mild injury to the developing tooth
germ during late secretory stage of
amelogenesis.15 Patients with enamel
defects on their anterior teeth often
have functional complaints of pain and
sensitivity, as well as aesthetic concerns,
which may be accompanied by psychosocial
and bullying issues.12
An 11-year-old girl was referred by her
GDP to the paediatric dental department
with concerns of sensitivity on cold stimuli
and self-esteem issues associated with
her upper front teeth. Her parent recalled
a history of dental trauma when she was
12 months old at home; however, no further
specific detail around the exact trauma
diagnosis was provided. She was otherwise
medically fit and well.
Following clinical and radiographic
assessment (Figure 3) the below diagnoses
were made:
 UR2, UR1 and UL1: severe
enamel hypoplasia;
14 DentalUpdate
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b
Figure 3. Pre-treatment of Case 1.
(a) Orthopantomogram and (b) long cone peri-
apical radiograph views.
 UR1: dilaceration of crown;
 UR2, UR1 and UL1: vital on sensibility
testing with no signs of pathology;
 LL6, LLE, LRE and LR6: caries;
 High caries risk;
 Generalized gingivitis;
 Incisor malocclusion: Class II division
1 with reduced overbite;
 Mixed dentition;
 Compliant for chairside dental
treatment under local anaesthesia.
Although it was recognized that
this patient could have been managed
in primary care alone, a treatment plan
for shared care was adopted owing to
the concerns expressed in the referral
about managing a potentially anxious
child with severe enamel defects. This
plan included:
1. Caries prevention: effective twice
daily oral hygiene, reduced frequency
and amount of dietary sugars and
acids, fluoride adjuncts, including
prescription of 2800ppm fluoride
toothpaste, regular fluoride varnish
application and fissure sealant of non-
carious first permanent molars (UR6
and UL6).
2. Caries management in primary
care: extraction of LLE and LRE and
restoration of LL6 and LR6.
3. Restoration of hypoplastic and
dilacerated teeth in secondary care:
composite build up under local
anaesthesia and dry dam of UR2, UR1
and UL1 (Figure 4).
4. Multidisciplinary team (MDT)
assessment for long-term treatment
planning of UR1, which had a guarded
prognosis, with management of
expectations of attendance for long-
term maintenance of treatment.
Initially this was likely to involve
monitoring of UR1 in primary care.
If it became non-vital, it was to be
planned for subsequent extraction
and prosthetic replacement, in
either primary or secondary care.
Orthodontic treatment with fixed
appliances may be required to idealize
spacing for the replacement UR1.
Learning points
Stabilization and prevention of
active pathology
A hypoplastic enamel surface places
the patient at increased caries risk.
For any patient, but particularly those
with complex treatment needs, active
caries and periodontal disease require
stabilization, ideally prior to the restorative
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a a
Figure 4. Photographs of Case 1. (a) Before
and (b) after restoration of enamel hypoplasia
affecting upper incisor teeth
a
b
b procedures, including composite
Figure 5. Photographs of (a) dry dam and hole
punch, and (b) how it is worn.
treatment phase, because this will
reduce gingival bleeding and risk of
secondary caries and thus improve
aesthetics and longer-term outcome.
Emphasizing the importance of
excellent oral hygiene and a non-
cariogenic diet, and placement of fissure
sealants in patients with increased caries
risk is key in delivering successful, long-
lasting restorative care.
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Figure 6. Pre-treatment of Case 2.
(a) Orthopantomogram and (b) upper standard
occlusal radiographic views.
Anxiety management
Hypoplastic teeth are often hypersensitive
and can be painful during non-invasive
bonding, so the use of local anaesthetic
can help ensure patient comfort and
build trust and confidence in the
treating dentist. Adopting behavioural
management techniques such as ‘tell,
show, do’, and distraction is recognized as
beneficial in earning cooperation in the
paediatric patient.16
Adhesive bonding
Effective moisture control is vital in
ensuring successful adhesion to resin
composite restorations. The use of
retraction cord for subgingival margins
and dry dam or rubber dam with clamp
to completely expose the defect should
be considered. (Figure 5) Hypomineralized
defects may also present in isolation,
or in conjunction with hypoplasia,
so deproteinization using sodium
hypochlorite (5.25%) for 60 seconds post-
etch can be used to increase the surface
area for improved adhesion.17
Paediatric Dentistry
Case 2: Dilaceration
Dilaceration is the abrupt structural
deviation or angulation of the long-axis
crown or root of a tooth, due to traumatic
non-axial displacement of the hard tissue
tooth germ.15 Up to 3% of permanent
teeth are dilacerated due to trauma to
their predecessors.3 Dilaceration of the
crown presents more frequently than root
dilaceration because it is the crown of
the permanent incisor that is developing
between the ages of 1 and 4 years when
primary dental trauma is more frequently
sustained.15,18 Depending on the site of
dilaceration and the degree of resultant
abnormality in morphology, eruption may
be delayed or fail, resulting in a partially or
completely unerupted tooth.15
A fit and well 7-year-old boy was
referred by his GDP due to concerns
regarding the palatal position of his
erupting UR1. He had previously attended
our paediatric dental department aged
20 months when he experienced severe
intrusion of URA and avulsion of ULA.
Following clinical and radiographic
examination (Figure 6), the following
diagnoses were made:
 UR1: severe dilaceration (crown
and root) and enamel hypoplasia;
poor prognosis;
 UR2: unerupted and impacted against
dilacerated UR1;
 UL1: unerupted and rotated;
 Incisal malocclusion:
Class III malocclusion;
 Chronic gingivitis;
 Mixed dentition;
 Good compliance for dental treatment.
During subsequent treatment, the following
diagnoses were also noted and managed:
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 Paediatric Dentistry
Figure 7. Orthopantomogram of Case 2 mid-treatment.
a d
2.
3.
b 4.
5.
6.
Figure 8. CBCT scan of Case 2 taken before
treatment. (a) 3D representation and (b) sagittal
slice showing ‘S-shaped’ UR1.
7.
 LLE and LRE: moderate infra-occlusion/
submerged (Figure 7);
8.
 Persistent chronic gingivitis;
 UR1: severe dilaceration ‘S-shaped’;
poor prognosis (Figure 8).
9.
This patient was assessed and treatment-
planned in the MDT clinic for treatment
that would be carried out in phases:
1. Caries prevention: effective twice daily
oral hygiene, reduced frequency and
16 DentalUpdate
pg12-20 Lau.indd 16
amount of dietary sugars and acids,
1450ppm fluoride toothpaste and
regular review in primary care.
Aid eruption of impacted and e
unerupted UR2, UR1, UL1 and UL2:
interceptive upper removal appliance
to ‘nudge’ UR1 into a more labial
position, and extraction of URC and
ULC under inhalation sedation and local
Figure 9. (a–e) Clinical photographs of Case 2.
anaesthesia (Figure 9a).
Provisional maintenance of UR1:
composite restoration (Figure 7 and 9b).
Evaluation of prognosis of UR1: CBCT
10. Improvement of UR2 upon completion
scan revealed it was ‘S-shaped’ and
of orthodontic therapy: polishing
would not be ideal to maintain alongside
of composite restoration and
orthodontic therapy (Figure 8).
gingivectomy (Figure 9e).
Orthodontic therapy: upper and lower
fixed appliance to correct malocclusion
and prepare movement of UR2 into Learning points
maxillary central incisor space. Phased treatment
Definitive management of poor As dilacerated teeth often remain impacted
prognosis UR1, orthodontic extraction and unerupted, it can be difficult to
for severe upper arch crowding accurately predict the success of bringing
and removal of retained upper and them into alignment. Phased treatment
moderately infra-occluded mandibular planning may provide the opportunity
to provide relatively simple, interim
primary second molars: extraction of
interventions aimed at addressing ongoing
URE, UR1, UL4, ULE, LLE and LRE under
patient concerns in a developing patient,
general anaesthesia (GA) (Figure 9c).
Review of dental development: while allowing a more complete, later
identification of crowding in assessment of restorability and long-term
developed permanent arch requiring prognosis as part of definitive treatment
orthodontic extraction planning. Keeping patients and their
Orthodontic extraction in primary parents informed of this approach from
care: extraction of LL5 and LR5 under the outset is important in managing their
local anaesthesia. expectations and promoting compliance
in attendance.
Masking UR2 as maxillary central
incisor: composite build-up of UR2,
completed during orthodontic fixed Assessment of prognosis
appliance therapy to move UR2 into The use of CBCT is helpful to assess
the maxillary central incisor space prognosis of unerupted dilacerated teeth.
(Figure 9d). Planned extraction of a poor prognosis
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Figure 10. Pre-treatment orthopantomogram of Case 3.
a and associated dentigerous cyst;
expectations. For instance, it enabled
our teams to address and manage the
patient’s concern about a ‘small front tooth’
(UR2) and the infra-occluding mandibular
primary molars in a timely manner.
b
Case 3: Dentigerous cysts
Dentigerous cysts are benign inflammatory
odontogenic lesions attached to an
unerupted tooth’s cervical region,
c enveloping its crown.19 The majority of
dentigerous cysts are developmental,
forming due to alteration of reduced
enamel epithelium, resulting in fluid
accumulation between the epithelium
and crown.20 In rare cases, dentigerous
d cysts may form around developing
permanent teeth in response to chronic
peri-apical inflammation from overlying
necrotic primary teeth, resulting in
inflammatory exudate accumulation
between the reduced enamel epithelium
Figure 11. (a–d) Clinical photographs of Case 3. and enamel layers.20–22 The presence of
such a dentigerous cyst then obstructs
the eruption of the permanent tooth,
resulting in its ectopic position. Although
permanent tooth during active dental some evidence suggests dentigerous
development can improve the overall cysts can disrupt amelogenesis resulting
prognosis of their adult dentition alongside in hypoplasia,23 the presence of additional
orthodontic and restorative management. dental anomalies (enamel hypoplasia and
dilaceration for example) are more likely
Multidisciplinary treatment planning to be the result of the original primary
The benefit of a joint specialty interface dental trauma rather than subsequent
in secondary care has been highlighted cyst development.
throughout this case. Joint clinic input from A 10-year-old girl was referred to
the start of his journey has ensured effective the orthodontic department with the
communication and good team working complaint of an unerupted UL1. She was
to complete each treatment phase and medically fit and well, but reported a
appropriately manage patient and parent persisting thumb-sucking habit. Her parent
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Paediatric Dentistry
reported a history of dental trauma to ULA
aged 3 years, the family understood that
this tooth had been lost (avulsed) at this
time. Plain film radiographs (Figure 10)
and CBCT imaging revealed that UL1 was
present, but dilacerated and horizontally
positioned. A sizeable dentigerous cyst
was noted to be associated with its crown.
CBCT revealed that the primary central
incisor (ULA) was retained and lying
superior to the permanent incisor root, in
a position closely related to the floor of
the nose.
Following clinical and radiographic
examinations, the following diagnoses
were made:
 UL1: severe root dilaceration, enamel
hypoplasia, horizontal ectopic position
 ULA: severe intrusion (submerged and
non-vital following earlier trauma);
 UR2: diminutive and potentially
transposed with upper left
maxillary canine;
 Chronic gingivitis;
 Incisal malocclusion: Class I
malocclusion with crowding;
 Mixed dentition;
 Good compliance for dental treatment.
Prompt assessment and treatment
planning following referral to our MDT
optimised the outcome for this patient
following delayed presentation:
1. Prevention of caries and exacerbation
of malocclusion: effective twice daily
oral hygiene, reduced frequency and
amount of dietary sugars and acids,
1450ppm fluoride toothpaste, regular
review in primary care and immediate
cessation of digit-sucking habit
(Figure 11a).
2. Removal of pathology: surgical removal
of submerged ULA and enucleation of
dentigerous cyst associated with crown
of UL1 under GA.
3. Space maintenance of UL1 space:
construction of upper removable partial
denture to prevent space loss in the
maxillary central incisor region while
monitoring UL1 eruption.
4. MDT review of developing dentition
9 months post-cyst enucleation: a
repeat CBCT (Figure 12) was taken
to assess prognosis of UL1. No
improvement in its position was noted
following surgical intervention and it
was declared poor prognosis.
5. Definitive management of poor
prognosis UL1, ectopic UL3 and
orthodontic extractions: surgical
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 Paediatric Dentistry
a 6. Orthodontic therapy: upper and lower
b
c primary incisor aged 4 years. The family
d
Figure 12. (a) 3D representation; (b) axial slice
showing horizontal position of UL1; (c) coronal
slice showing UL1 pericoronal cys; and (d) sagittal
slice showing UL1 dilaceration.
removal of UL1, exposure and bonding
of gold chain to UL3 and extraction of
URE, UR4, ULC, ULE, LL5, LLE, LRE and
LR5 under GA (Figure 11b).
18 DentalUpdate
pg12-20 Lau.indd 18
fixed appliances to correct malocclusion,
prepare movement of UL2 into maxillary
central incisor space and align the
ectopic UL3 (Figure 11c).
7. Masking UL2 as the maxillary central
incisor and UL3 as the adjacent lateral
incisor: composite build-up of UL2,
completed during orthodontic fixed
appliance therapy.
8. Polishing of composite restorations at
time of orthodontic bracket debonding
and long-term retention with vacuum-
formed retainers (Figure 11d).
Learning points
Primary dental trauma management
All patients who have experienced primary
dental trauma should be regularly reviewed
as part of dental trauma guidelines.5 It
is important to account for suspected
avulsed teeth at the time of injury and
radiographic assessment can be used to
identify whether traumatized teeth have
truly been avulsed or if, in fact, they are
retained and intruded. Engaging parents
and ensuring that they appreciate the need
for regular, long-term follow up of their
child’s dentition at the time they present
with primary dental trauma is essential. A
description of the possible sequelae to the
permanent dentition is imperative to avoid
their loss to follow up and associated late
presentation for future treatment needs.
A clear, but empathetic, discussion at this
stage prevents lack of parental education
and prioritization being a barrier to their
child accessing the dental care that they
require later.
Timely referral
Regular monitoring and the identification
of an unerupted tooth is needed to ensure
timely referral for specialist care. The Royal
College of Surgeons guideline defines
an unerupted maxillary incisor as the
absence of eruption of the incisor more
than 6 months after the eruption of the
contralateral incisor, or more than 1 year
following the eruption of the mandibular
incisors.24 Early diagnosis and appropriate
management, often consisting of MDT input
is recommended.
Dentigerous cyst management
The overarching aim of dentigerous cyst
enucleation is to remove cystic epithelium
and allow bony infill of the remaining cavity.
A conservative approach is often taken to
allow this process to occur. Following bony
infill and healing, a second GA episode
may be planned due to complications
involving the associated unerupted tooth. It
is important to discuss with the patient and
family the possible need for repeat GA and
risk of lack of eruption as a consequence of
dilaceration and/or additional ankylosis.
Case 4: Nasal complications
Maxillary sinus mucocele is an uncommon
(3–10%),25 cyst of the paranasal epithelial
lining that develops as a consequence
of the obstruction of the maxillary
sinus ostium and subsequent mucus
accumulation. This phenomenon is reported
to result from the presence of chronic
sinusitis, polyps, tumours and trauma.26,27
Slow-growing maxillary sinus mucocele
development following facial fracture has
been reported,28,29 although there has
not been any reported cases of mucocele
development following dental trauma.
An 8-year-old boy presented to the
paediatric dental department complaining
of a retained maxillary primary incisor
and unerupted permanent central
incisor. He had a history of trauma to his
had been informed by his GDP that UL1
may be dilacerated as a consequence
of the earlier trauma and that this
tooth may require surgical intervention.
At his first consultation the patient’s
mother revealed her concerns about
his recurrent nosebleeds; his General
Medical Practitioner had made a referral
to local ear, nose, throat (ENT) services,
but no appointment had been scheduled.
The patient was otherwise medically fit
and well.
Following clinical and radiographic
examination and assessment, the following
diagnoses were made:
 UL1: ectopic and unerupted, mild-
moderate root dilaceration;
 ULA: retained;
 Medical history of daily, heavy
nosebleeds worsening over the previous
couple of years;
 Soft tissue lesion in the left maxillary
sinus closely related to unerupted UL1
(incidental finding) (Figures 13 and 14).
The following treatment was, subsequently,
planned and completed:
1. Prevention of caries: effective twice
daily oral hygiene, reduced frequency
and amount of dietary sugars and acids,
1450ppm fluoride toothpaste and
regular review in primary care.
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a a
Figure 13. Pre-treatment of Case 4.
(a) Orthopantomogram and (b) upper standard
occlusal radiographs.
2. Removal of obstruction to UL1
eruption: extraction of ULA under local
anaesthetic (Figure 15a.)
3. MDT assessment regarding
the failure of UL1 to erupt: no
spontaneous improvement 1 year
after ULA extraction, decision to
begin orthodontic therapy made.
Completion of CBCT (Figure 14).
4. Orthodontic therapy: upper and lower
fixed appliances to open space at the
maxillary central incisor site.
5. ENT referral: new referral sent directly
to ENT colleagues highlighting
continued nosebleeds and the
presence of a soft tissue mass within
the left maxilla that appeared to
extend into the nasal cavity.
6. Review of UL1: spontaneous eruption
of UL1 after space creation, allowing
it to be brought into alignment.
January 2024
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Paediatric Dentistry
Orthodontic fixed appliance therapy
was completed and appliances
debonded for MRI scanning with the
ENT team. Retainers were fitted (Figure
15b).
7. ENT assessment: following MRI scan
c
that suggested the diagnosis of
maxillary sinus mucocele, endoscopic
excision and drainage of lesion
was performed. Histopathological
assessment of surgical specimen
confirmed the provisional diagnosis of
a mucocele.
8. Review of dental development.
Learning points
Initial management of unerupted maxillary
central incisors
As recommended by RCS guidelines, the
first line of management is removal of the Figure 14. CBCT. (a) Sagittal slice; (b) axial slice;
obstruction.24 Completion of this phase (c) coronal slice of the soft tissue lesion in the
in primary care is essential prior to MDT maxillary sinus.
assessment. Alongside space maintenance
or opening of space, unerupted maxillary
incisors with root growth potential are
Further research
likely to erupt into the arch.
Maxillary sinus mucocele due to dental
trauma is not currently reported.
Significance of multispecialty liaison with Further research in this area to confirm
medical ENT team an association could be helpful in
Families may find accessing health management of similar cases, despite its
services difficult, especially during the rare presentation.
COVID-19 pandemic when only urgent
referrals were accepted. Clinicians are well
placed in supporting referrals through Conclusion
letter correspondence detailing clinical Primary dental trauma resulting in
and radiographic findings as part of the avulsion, intrusion of the primary incisor
referral process. or associated alveolar fracture are more
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 Paediatric Dentistry
a effect on the development of permanent
b a clinical follow-up study. Oral Surg Oral
Figure 15. Photographs (a) following extraction
of primary incisor and (b) after treatment.
likely to result in complications affecting
the successor tooth. Appropriate
management of these should include
regular active monitoring, parent
education regarding possible sequelae,
and age-appropriate referral to specialist
services if required. Application of the
learning points described in this article
may help practitioners manage primary
dental trauma and the sequelae.
Acknowledgements
Thank you to Lauren Lau for designing
the digital artwork and to Dellesha
Wallace for modelling the dry dam.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Petti S, Glendor U, Andersson L. World
traumatic dental injury prevalence and
incidence, a meta-analysis. One billion
living people have had traumatic dental
injuries. Dent Traumatol 2018; 34: 71–86.
https://doi.org/10.1111/edt.12389
2. Caeiro-Villasenín L, Serna-Muñoz C,
Pérez-Silva A et al. Developmental dental
defects in permanent teeth resulting from
trauma in primary dentition: a systematic
review. Int J Environ Res Public Health
2022; 19: 754. https://doi.org/10.3390/
ijerph19020754
3. Andreasen JO, Sundström B, Ravn JJ. The
effect of traumatic injuries to primary
teeth on their permanent successors.
I. A clinical and histologic study of 117
injured permanent teeth. Scand J Dent
Res 1971; 79: 219–283. https://doi.
org/10.1111/j.1600-0722.1971.tb02013.x
4. Lenzi MM, da Silva Fidalgo TK, Luiz RR,
Maia LC. Trauma in primary teeth and its
20 DentalUpdate
pg12-20 Lau.indd 20
successors: a controlled study. Acta
Odontol Scand 2019; 77: 76–81. https://
doi.org/10.1080/00016357.2018.1508741
5. Day P, Flores MT, O’Connell A, et al.
International Association of Dental
Traumatology guidelines for the
management of traumatic dental injuries:
3. Injuries in the primary dentition. Dent
Traumatol 2020; 36: 343–359. https://doi.
org/10.1111/edt.12576
6. Holan G. Development of clinical and
radiographic signs associated with dark
discolored primary incisors following
traumatic injuries: a prospective
controlled study. Dent Traumatol 2004; 20:
276–287. https://doi.org/10.1111/j.1600-
9657.2004.00285.x
7. Glendor U, Halling A, Andersson L, Eilert-
Petersson E. Incidence of traumatic tooth
injuries in children and adolescents in the
county of Västmanland, Sweden. Swed
Dent J 1996; 20: 15–28.
8. Patnana AK, Chugh A, Chugh VK et al. The
prevalence of traumatic dental injuries
in primary teeth: a systematic review
and meta-analysis. Dent Traumatol 2021;
37: 383–399. https://doi.org/10.1111/
edt.12640
9. Nguyen QV, Bezemer PD, Habets L,
Prahl-Andersen B. A systematic review
of the relationship between overjet
size and traumatic dental injuries. Eur J
Orthod 1999; 21: 503–515. https://doi.
org/10.1093/ejo/21.5.503
10. Moss SJ, Maccaro H. Examination,
evaluation and behavior management
following injury to primary incisors. N Y
State Dent J 1985; 51: 87-92.
11. NHS England. Clinical standard for
Paediatric Dentistry. 2023. Available
at: www.england.nhs.uk/long-read/
paediatric-dentistry/ (accessed December
2023).
12. Rodd H, Noble F. Psychosocial impacts
relating to dental injuries in childhood: the
bigger picture. Dent J (Basel) 2019; 7: 23.
https://doi.org/10.3390/dj7010023
13. Mittal R, Chandak S, Chandwani M, et
al. Assessment of association between
molar incisor hypomineralization and
hypomineralized second primary molar.
J Int Soc Prev Community Dent 2016; 6:
34–39. https://doi.org/10.4103/2231-
0762.175409
14. Patel A, Aghababaie S, Parekh S.
Hypomineralisation or hypoplasia? Br
Dent J 2019; 227: 683–686. https://doi.
org/10.1038/s41415-019-0782-9
15. von Arx T. Developmental disturbances
of permanent teeth following
trauma to the primary dentition. Aust
Dent J 1993; 38: 1–10. https://doi.
org/10.1111/j.1834-7819.1993
16. American Academy of Pediatric Dentistry.
Behavior guidance for the pediatric dental
patient. The Reference Manual of Pediatric
Dentistry. Chicago, IL, USA: American
Academy of Pediatric Dentistry, 2023;
359–377.
17. López-Luján NA, Munayco-Pantoja ER,
Torres-Ramos G et al. Deproteinization of
primary enamel with sodium hypochlorite
before phosphoric acid etching. Acta
Odontol Latinoam 2019; 32: 29–35.
18. Altun C, Cehreli ZC, Güven G, Acikel C.
Traumatic intrusion of primary teeth and
its effects on the permanent successors:
Med Oral Pathol Oral Radiol Endod 2009;
107: 493–498. https://doi.org/10.1016/j.
tripleo.2008.10.016.
19. Speight P, Fantasia JE, Neville BW.
Dentigerous cyst. In: El-Naggar AK,
Chan JKC, Grandis JR et al (eds). WHO
Cassification of Head and Neck Tumours.
4th edn. Lyon, France: IARC, 2017; 234–235
20 Benn A, Altini M. Dentigerous cysts of
inflammatory origin. A clinicopathologic
study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1996; 81: 203–209. https://doi.
org/10.1016/s1079-2104(96)80416-1
21. Sannomiya EK, Nogueira Mde Q, Diniz Mde
C et al. Trauma-induced dentigerous cyst
involving the anterior maxilla. J Dent Child
(Chic) 2007; 74: 161–164.
22. Gondim JO, Neto JJ, Nogueira RL, Giro EM.
Conservative management of a dentigerous
cyst secondary to primary tooth trauma.
Dent Traumatol 2008; 24: 676–679. https://
doi.org/10.1111/j.1600-9657.2008.00616.x
23. Al-Talabani NG, Smith CJ. Experimental
dentigerous cysts and enamel hypoplasia:
their possible significance in explaining the
pathogenesis of human dentigerous cysts.
J Oral Pathol 1980; 9: 82–91. https://doi.
org/10.1111/j.1600-0714.1980.tb01390.x
24. Yaqoob O, O’Neill J, Patel S et al.
Management of unerupted maxillary
incisors. 2022. Available at: https://
www.rcseng.ac.uk/dental-faculties/fds/
publications-guidelines/clinical-guidelines/
(accessed December 2023)
25. Natvig K, Larsen TE. Mucocele of the
paranasal sinuses-a retrospective clinical
and histological study. J Laryngol Otol 1978;
2: 1075–1082.
26. Mohan S. Frontal sinus mucocele with
intracranial and intraorbital extension: a
case report. J Maxillofac Oral Surg 2012; 11:
337–339. https://doi.org/10.1007/s12663-
010-0163-z
27. Costan VV, Popescu E, Stratulat SI. A
new approach to aesthetic maxillofacial
surgery: surgical treatment of unilateral
exophthalmos due to maxillary sinus
mucocele. J Craniofac Surg 2013; 24:
914–916. https://doi.org/10.1097/
SCS.0b013e318287d154
28. East D. Mucocoeles of the maxillary
antrum. Description, case reports and
review of the literature. J Laryngol Otol
1985; 99: 49–56. https://doi.org/10.1017/
s0022215100096274
29 Hasegawa M, Saito Y, Watanabe I, Kern EB.
Postoperative mucoceles of the maxillary
sinus. Rhinology 1979; 17: 253–256.
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