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

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M. L. ODERSJÖ, G. KOCH

intrusive injuries to the primary predecessors and that was now caring for each child. At the follow-
relate this to the degree of intrusion, the age of the up examination and from previous dental records,
child, the developmental stage of permanent tooth the following information [modified from
germ and the treatment given. Knowledge of Andreasen and Ravn 1971; von Arx 1995] was
factors influencing the frequency and severity of collected.
complications are important in the prediction of - Sex.
disturbances resulting from trauma. - 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
Materials and methods yet turned 3).
In this study were included all children who had - The tooth or teeth that were traumatized.
been referred to the Department of Paediatric - The developmental stage of the permanent
Dentistry, The Institute for Postgraduate Dental successor at the time of trauma as:
Education, Jönköping, Sweden (IPGDE), because mineralization of the incisal part;
of trauma resulting in the intrusion of a primary mineralization of about half of the crown;
incisor were at least 8 years old at the time of the mineralization of the entire crown.
study, and had fully erupted permanent maxillary - The degree of intrusion of the primary incisors
central incisors. With one exception, children who at the time of trauma:
had undergone more than one traumatic incident less than half of the crown was intruded;
were excluded. half or more of the crown was intruded;
The study population, therefore, consisted of 95 all of the crown was intruded (complete).
children who had experienced a traumatic - Treatment given to the intruded incisor at the
intrusion of a primary incisor between 1973 and time of trauma and later:
1997. Most of the trauma had happened by falling - no extraction
against the ground or furniture while playing. re-eruption without complications,
Only few trauma were caused by traffic accidents. re-eruption with mild complications
The children had been given emergency treatment (obliteration or colour changes with no
at IPGDE and the more detailed treatment was radiographically verified signs of periapical
pending. Improved oral hygiene and infection);
abandonment of the use of pacifiers was advised. - extraction of the intruded incisor
Antibiotics were seldom prescribed. Radiographs immediately (within 1 week),
were available from the time of the trauma for all later because of complications (pulp necrosis
the children. They all had been followed up, with radiographically verified signs of
clinically and radiographically, for several years periapical infection, long-lasting mobility in
depending on healing and treatment. combination with periapical infection,
All 95 children were called for a follow-up anchylosis, or fistula).
examination of any sequelae in the permanent - Complications in the erupted permanent
successors because of the intrusive trauma of their successor (a tooth can show more than one
primary incisors. Fifteen of the children had complication):
moved from the area and 10 declined to white or yellow-brown enamel hypo-
participate. mineralisation;
Thus 70 children (29 girls and 41 boys) with a localised enamel hypoplasia;
total of 118 intruded teeth (38 had one intruded hypomineralisation and circular enamel
tooth, 23 had two teeth, 2 had three teeth, and 7 hypoplasia;
had four teeth) were examined by one of the crown dilaceration;
authors (MLO) concerning their permanent odontoma-like malformation;
incisors (Table 1). One boy who had been exposed disturbed root development;
to intrusive trauma on two occasions but which sequestered tooth germ;
involved different teeth was included. The follow- disturbed eruption;
up included both a clinical and a photographic no changes.
examination. Prior to this clinical examination, all
recent radiographs of the maxillary incisor region These different outcomes are illustrated in
were requested from the Public Dental Service figures 1-5.

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 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.

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

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M. L. ODERSJÖ, G. KOCH

half or more of the crown was intruded (Table 3). extracted immediately or later. About 80% of the
Irrespective of the developmental stage of the extraction cases developed complications in the
permanent tooth at the time of trauma, about 75% permanent successor compared with about 65% in
of the teeth had complications. The more serious the no extraction group. Almost all the serious
complications were found when the trauma had complications were found in the late extraction
occurred before the entire crown of the permanent group.
successor was mineralised (Table 3).
In 19 of the 21 teeth that had severe
complications (hypomineralization and circular Discussion
enamel hypoplasia or worse), intrusion was half or The present study is retrospective, descriptive in
more of the crown and had occurred when the nature. The rather small subgroups within the
child was under the age of 3 years (Table 2, 4). material did not allow us to perform meaningful
In Table 5 it can be seen that a higher percentage statistical analysis on differences between the
of permanent successors had complications in groups. When analysing the results it must also be
those children where the intruded incisor had been 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 1 2 4 7
Hypomin. + circular enamel hypoplasia 4 6 2 12
Crown dilaceration 1 1 1 3
Odontoma-like malformation 0 1 0 1
Disturbed root development 0 0 1 1
Sequestered tooth germ 0 0 0 0
Disturbed eruption 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

 PRIMARY TEETH INTRUSION

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