The most frequent consequences of primary tooth trauma in permanent dentition include white or yellow opacity, enamel hypoplasia, crown dilaceration, root angulation, arrest of root development and eruption disturbance. These anomalies may vary from enamel hypocalcification to arrest of the permanent bud’s growth, according to the stage of development and maturation of both the traumatized primary tooth and the correspondent
permanent germ and to the intensity and direction of the trauma itself. Crown dilacerations are more common between 1.5 and 3.5 years of age, while root malformation between 4 and 5 years of age. (1) In general, immediately after a dental alveolar trauma in the primary dentition, no definite statement can be made regarding the possible secondary damage despite clinical and radiological examinations. The type of traumatic primary tooth injury combined to the age of the child at the time of the accident can indicate the probability of subsequent secondary damages. Thus, the importance of accurate exploration and documentation of the accident becomes apparent. Especially in cases of intrusion injuries diagnosed in children of <3 years of age, werecommend regular follow-ups. In particular pre-eruptive radiology is recommended, to achieve early detection and treatment of possible severe developmental disturbances. (2-7)
An 8-year-old female patient referred to our clinic to solve the esthetic problem of #21. Parents mentioned a primary anterior teeth trauma at the age of 8 months. They weren’t able to remember the kind of trauma, except the fact that there was a lot of bleeding. They had visited only a paediatrician, with no other special concerns about possible sequelae.
Clinical examination revealed enamel hypoplasia and deformation of crown of #21 and absence of eruption of #11. The type and degree of damage to the permanent tooth is related to the developmental phase of the permanent tooth germ at the time of intrusive injury to the primary tooth predecessor. Trauma occurring at younger ages is more likely to affect only the crown of the permanent tooth, whereas at older ages both the root and crown are likely to be affected. Although the upper permanent central incisor germ is formed at 20 weeks of gestation, calcification does not begin until 3-4 months of age. Because ameloblasts are irreplaceable, and no further cell division occurs after enamel formation is complete, trauma is likely to be followed by a localised arrest of crown development. Destruction of the ameloblasts in the active enamel epithelium will also result in enamel hypoplasia. (8-10) According to Andreasen et al (11) and Altun et al (10) hypoplastic defects may be the result of localized damage to the enamel matrix before the completion of mineralization.
Cone Beam computed tomography (CBCT) examination revealed the disturbance of eruption of #11.
The trauma to the primary tooth is transmitted directly to the developing crown of the permanent bud due to the close proximity of the primary tooth root and the developing enamel organ. The effect of trauma to the Hertwig’s epithelial root sheath is the result of the transmission of the traumatic force through the surrounding bone or through the primary tooth, causing deflection or displacement of the permanent bud. (12-13). Patient referred to
both orthodontist and oral surgeon for inverted #11.
Initial clinical image of #21 with circular enamel hypoplasia and crown deformation. Two different approaches were performed. First resin infiltration to mask yellow and brown areas, which will allow us to proceed to the restoration with composite resin, without removing any tooth substance and be less invasive. Recently resin infiltration technique has shown promising results on developmentally hypomineralized enamel lesions, which affect the full tissue thickness. (14-15) In hypomineralized lesions associated with post-eruptive breakdown of enamel, infiltration of the lesion prior to composite resin restoration may also improve the bonding efficacy. (15-16)
After resin infiltration we proceeded with composite resin restoration with CompoSIte, White Dental Beauty
Color matching and analysis must be performed before rubber dam isolation when the teeth are fully hydrated, otherwise, there is a high risk of mismatching color. Before infiltration technique, according to dentin selection, Whiteology, CompoSite dentin shade Si2 would be used to layer.
The infiltration technique should be applied under strict isolation.
After rinsing and drying with compressed air, we proceed with the application of ethanol (ICON-Dry) for 30 seconds and inspect thoroughly. Thereafter, the teeth should be dried with compressed air.
Final step is the application of the infiltration resin (ICON infiltrant). Then, light curing for 40 seconds and reapplication of the resin infiltrant. Clinical image #21 with the final view of the infiltrated lesions. Obviously infiltration masked yellow and brown areas, so we can be less invasive in the second approach. Composite restoration will result in an acceptable anatomic contour. We proceed with bonding procedures.
The White Dental Beauty CompoSite system only features one enamel shade, which has been designed to blend flawlessly with all the Si universal shades. Thanks to its calibrated translucency and opalescence, it is ideal for a two-layer technique or to simply characterize the incisal edge. Clinical image after application of dentin Si2.
Immediately after finishing, polishing and removal of rubber dam.
Immediate postoperative view of #21 under different lighting conditions: Cross-Polarization (polar_eyes Cross polarization filter).
Two-week postoperative view of #21. The final situation, with correct shape, shade and contour, and a polished surface.
Two-week postoperative view of #21 under different lighting conditions: Cross-Polarization (polar_eyes Cross polarization filter).
Edge to egde position highlighting the micro-morphology of the incisal edge of #21 composite restoration.
Micro-morphology and microstructure of #21 composite restoration with CompoSIte, White Dental Beauty Composite. Patient already referred to an orthodontist and dental surgeon for the treatment of unerupted #11.
The infiltration technique offers the opportunity of ultraconservative management of enamel hypoplasia lesions, related to primary tooth predecessor injury. Simple two layer techniques with new materials, simplify the procedure of anterior direct composite restorations and make them predictable, repeatable and easy to correct in the future of a young patient. Also, decrease chairside time which is a main importance factor in pediatric dentistry. Final result is highly acceptable for a no-prep approach and minimally invasive for a young patient.
1. Bardellini E, Amadori F, Pasini S, et al. Dental anomalies in per- manent teeth after trauma in primary dentition. J Clin Pediatr Dent. 2017;41:5–9.
2. Sennhenn-Kirchner S, Jacobs HG. Traumatic injuries to the primary dentition and effects on the permanent successors a clinical follow-up study. Dent Traumatol. 2006;22:237–241.
3. Avsar A, Topaloglu B. Traumatic tooth injuries to primary teeth of children aged 0–3 years. Dent Traumatol. 2009;25:323–7.
4. Malmgren B, Andreasen JO, Flores MT, et al. Guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2012;28:174–428.
5. Tewari N, Mathur VP, Singh N, et al. Long-term effects of traumatic dental injuries of primary dentition on permanent successors: a retrospective study of 596 teeth. Dent Traumatol. 2018;34:129–134.
6. Skaare AB, Aas AL, Wang NJ. Enamel defects on permanent successors following luxation injuries to primary teeth and carers’ experiences. Int J Paediatr Dent. 2015;25:221–228.
7. Michele Machado Lenzi, Tatiana Kelly da Silva Fidalgo, Ronir Raggio Luiz & Lucianne Cople Maia (2018): Trauma in primary teeth and its effect on the development of permanent successors: a controlled study, Acta Odontologica Scandinavica
8. Flores MT, Onetto JE. How does orofacial trauma in children affect the developing dentition? Long-term treatment and associated complications. Dent Traumatol. 2019;35:312-23.
9. Lenzi MM, Alexandria AK, Ferreira DM, Maia LC. Does trauma in the primary dentition cause sequelae in permanent successors? A systematic review. Dent Traumatol. 2015;31:79-88.
10. Altun C, Cehreli ZC, Güven G, Acikel C. Traumatic intrusion of primary teeth and its effects on the permanent successors: a clinical follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:493-8.
11. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic Injuries to the teeth. 4th ed. Copenhagen: Munksgaard; 2007.
12. Zilberman Y, Ben-Bassat Y, Lustmann J, Fuks A, Brin I. Effect of trauma to primary incisors on root development of their permanent successors. Pediatr Dent 1986;8:289–93.
13. do Espírito Santo Jácomo DR, Campos V. Prevalence of sequelae in the permanent anterior teeth after trauma in their predecessors: a longitudinal study of 8 years. Dent Traumatol. 2009;25(3):300-304.
14. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration—a clinical report. Quintessence Int 2009;40:713–8.
15. Zafer Cehreli, Infiltration: Ultraconservative Management of Hypomineralization, https://www.styleitaliano.org/infiltration-ultraconservative-management-of-hypomineralization/
16. Wiegand A, Stawarczyk B, Kolakovic M, Hammerle CHF, Attin T, Schmidlin PR. Adhesive performance of a caries infiltrant on sound and demineralised enamel. J Dent 2011; 39: 117–121.
17. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS. Stratification in anterior teeth using one dentine shade and a predefined thickness of enamel: A new concept in composite layering – Part II. Odontostomatol Trop 2014; 37(47): 5-13