Pédiatrie Dentistry!

Intrusion injuries of primary incisors.Part i: Review and managementMai Diab, DDS, MScVHossam E. ElBadrawy, DDS, MS^

Intrusion injuries commonly occur in the primary dentition. They can be described as luxation injuriesresulting from an axially directed impact, which drives the tooth deeper into the alveolar socket. Theimpact results in compression of and damage to the periodontal ligament as well as injury to the pulp ofthe intruded incisor. In addition to rendering treatment to the intruded primary tooth, the dentist must alsobe aware of the possibility of an injury to the developing permanent teeth germs located in ciose proximityto the roots of the injured primary teeth. This review will discuss the charactenstics, implications, and man-agement of intrusion injuries of primary incisors. (Quintessence !nt 2000:31:327-334)

Key words: intrusion, primary tocth, tooth injury, trauma

The reported prevalence of traumatic injuries in pri-mary teeth varies among different studies and

ranges between lP/o and 30%.'-^ There are no signifi-catit differences in prevalence of dental injury betweenmales and females during the first year of life. Studiessuggest a higher prevalence of primary tooth injuriesin males after the first year; reported male-femaleratios range from 1.2:1 to 1.82:1.^-''-" The primaryteeth most frequently injured are the maxillary centralincisors; their percentage of injury ranges between63% and 92%.'-''^-'^-'^

Traumatic injuries in primary teeth result mainlyfrom indoor injuries, such as falling from baby car-riages, falling down stairs, or falling against hardobjects.*''-"-'^"'* Less frequently, injuries may occurwhile a child is playing outdoors or as a resuh of roadaccidents.*''^'''''"'' In addition, child abuse is highlyassociated with head and teeth injuries.^'" Suspicioustraumatic signs should alert the dentist to the possibil-ity of child neglect or abuse, and a comprebensivequestionnaire and report should be completed.-^-'

Traumatic injuries are less frequent during tbe firstyear of life.^'"" Their frequency increases during thetoddler stage, when the child starts crawling, walking,and expîoring the surrotinding environment. -^^ Thisincrease is mainly due to a lack of motor coordination

' Clinical Assistant Professor, Division of Pédiatrie Denlistry, Departmenl ofDentistry, University of Alberta, Edmonton, Alberta, Canada.

' Professor and Director, Division of Pédiatrie Dentistry, Department ofDentistry, University of Alberta, Edmonton, Alberta, Canada.

Reprint requests: Dr M. Drab, 4021-Dentistry/Pharmacy Centre, Facultyof Medicine and Dentistry, University ol Alberta, Edmonton, Alberta. T6G2NB Canada. E-mail: mdiab@ualberta.ca

and the rudimentary stage of development of reflexesthat function to protect the face from injuries.'•"• ''• '• 'As children mature, they become aware of possiblerisks and develop the necessary self-protective reflex

The reported peak incidence period for occurrenceof traumatic injuries to primary teeth varies. Somereports place that period between 1 and 2 years, ' ' ' *while other studies indicate a peak incidence betweenthe ages of 1.5 and 3.5 years.*''' •"•' •'*' '' '' Intrusion ofprimary incisors rarely happens after the age of 4years; tbe peak incidence is between 1 and 3 years ofage. ' Tbis is explained by tbe tendency for intrusionto occur wben primary incisor roots are fully formed.After tbe beginning of root résorption, around tbe ageof 4 years, other luxation injuries, such as avulsion,become more frequent."

Difl'erent types of traumatic injuries affect the pri-mary dentition, but studies bave sbown that tbe pri-mary incisors are bighly susceptible to luxation (dis-placement) injuries, sucb as intrusion. ' • •" This canbe attributed to the presence of large bone marrowspaces, whicb are characteristic of growing skeletal tis-sues, resulting in elasticity of tbe alveolar bone sur-rounding the primary teetb.'^"'^'^' In addition, theshort, resorbing roots and the high crown-root ratio ofthe primary teeth offer less resistance to intrusive dis-

Luxation injuries constitute 2P/o to 81% oftraumatic injuries of tbe primary teeth,"'•' •"'' • *' '>" and4.40/0 to 22% are intrusive luxation ínjuries.' 6- ''f''''"''5-i -í2The probability of a root or crown fracture increases astbe cbild gets older because of tbe mineralization andincreased rigidity of tbe alveolar bone.'' ' '"- ' ''

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EXAMINATION PROTOCOL

History

The child's medical history should always be discussedwith the parents. The need for prophylactic antibioticcoverage for infective endocarditis as well as the cur-rent tetanus immunization status should he deter-mined."•^^• ' Children gain active immunity from aseries of injections of diphtheria, pertussis, tetanus(DPT) vaccine during the first 18 months of life. Atage 6 years and every 10 years thereafter, a boostershould he given. After a traumatic injury and contactwith soil, a hoostcr is indicated if the patient has notreceived an immunization within the last 5 years,"^'

A dental history would indicate any past traumaticinjury or other dental experiences. This helps in deter-mining the child's maturation and the ability to coop-erate during treatment."'^ The history of the injuryshould be discussed with the parents. When, where,and how the injury happened should he recorded indetail,^^•^*" This information could he pertinent iffuture litigation is likely.

Behavioral considerations

Injury to the child patient is a traumatic experience onthe physical level as well as emotional and psycho-logic levels. Managing traumatic injuries for a child isa challenging and demanding task that requires a greatdeal of confidence and experience. Making the taskmore difficult is the child's age.

Children younger than 3 years have a limitedvocahulary that restricts their ability to communicate.Communicating with these children by words alonemay he difficult. Allowing them to adapt to the newdental environment by smelling, touching, and han-dling objects is essential. In addition, because childrenat this age become easily frightened, avoidance of jerkymovements and bright lights is critical. * Most impor-tant, these young children fear strangers and are highlyattached to their parents,*'"'' Separating infants andtoddlers from their parents is not advised.''""'' Parentsshould be informed that the child is expected to cryduring the procedure and that gentle restraint might benecessary.

Examination of a young child who has sustained atraumatic injury is best performed in a private consul-tation room. The parents' help is essential to conductthis procedure, by coordinating an adequate examina-tion position with the dentist An efficient position is aknee-to-knce position in which the dentist and theparent are seated face-to-face and the child is lying ontheir laps. The dentist holds the child's head, whilethe parent restrains the child's legs and

Another convenient position is having Hu' fv i rit siton the dental chair with the child on th: \)!'n-nt's lap.This position is adequate for botb the clJ •" jl ^nd theradiologie examinations and allows the |j;i) -nt to helprestrain the child's movements and hold the radio-graphic films, ^"' -' Adequate shielding from x-rays isnecessary for both child and parents.

Ciinicai examination

Clinical examination should commence with a neuro-logic assessment to detect signs of central nervous sys-tem damage. Cyanosis, nausea, vomiting, seizure activ-ity, and loss of consciousness may be indicators ofneurologic damage. Other signs are unsteadiness,abnormal respiration, slurred speech, rhinorrhea, otor-rhea, and abnormal eye movements."- '''' In the pres-ence of these signs, the child must be hospitalized fordetailed neurologic evaluation.

Following the visual assessment, an extraoral evalu-ation is done, including an examination of the headand neck, temporomandibular joint, and mandihularfunctions,^"'""'^^ Lacerations or contusions on theface or the chin should be cleaned thoroughly. Thiswill calm the child and parent and allow for betterexamination of the field of injury.

Intraorally, the lips, tongue, gingival tissues, andoral mucosa should be examined.'" Although intru-sion of primary incisors is associated with both upperand lower lip injuries,'^ contusions of the lower lipand the chin are more frequent." If soft tissue lacera-tions are present, and depending on the circumstancesoí the injury, a soft tissue radiograph may be helpful indetecting the presence of foreign bodies that may havebeen impacted within lip or tongue lacerations."*'"'^ Asmall-sized film is placed beneath the lip or tongue,and the radiograph is exposed at 25% of the normalexposure time.^^'^' The embedded foreign objectshould be removed at this stage to lessen the risk of achronic infection or exaggerated fibrosis. ' ""

The visual intraoral inspection of an intrudedincisor shows a tooth that is submerged in the alveolarbone away from the normal line of occlusion. Thedegree of intrusion can be divided into 3 grades.Grade I represents mild partial intrusion in wbichmore than SO /b of the crown is visible (Fig 1). GradeII represents moderate partial intrusion in which lessthan 50% of the crown is visible (Fig 2). Grade IIIrepresents severe or complete intrusion of the crown'''{Figs 3 and 4),

Bleeding may be noticed around the intruded tooth,which is not usually mobile or sensitive to palpation.'^Percussion testing may reveal a metallic sound buttenderness to percussion is a rare finding.'*^ " Becauseof the resiliency of the alveolar bone, the tooth may

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GRADE I

Fig 1 Mild intrusion of the maxillary right central incisof (tooth 51 [ED Less than50% of the orown is intruded.

GRADE II

Fig 2a Moderale intrusion of the maxillary left cen-tral incisor (tooth 61[F]). The incisai edge is visiOie,but a radiograph is essential to determine the direc-tion cf the intrusion.

Fig Zb Occlusal radicgraph showing a palatal intrusion oftooth 61. which invaded the germ of its permanent succes-sor The paiatally intruded incisor moves away from the x-raysource and appears elongated on the radiographie image.

become completely intruded and invisible as a resultof tbe blood clot and the gingival edema surroundingthe incisa! edge,«''«"" In this case, the parents or thedentist may think that the incisor is lost. A radiographwifl confirm the presence of the tooth (Fig 4), whichmay be located buccal to the cortical plate or even inthe nasal cavity.""

When tbe tooth is partially intruded, it becomes eas-ier to assess the orientation of displacement. A labialcrown orientation indicates a palatal intrusion of tberoot toward the permanent tootb germ. Conversely, apalatal crown inclination indicates a buccal intrusionof the root away from the successor germ, ''

Crushing and compression of the alveolar bone is anintegral part of an intrusive luxation injury. "** Fractureof tbe alveolar socket may accompany intrusion injuriesof higb impact, such as falling down a staircase. '"''' ' 'Signs of alveolar fracture can be detected by genfle pal-pation of tbe mucosa in tbe traumatized area, hi thiscase, the injured teeth and the cortical bone will moveas a unit. Furthermore, because of the natural promi-nent labial curvature of primary incisor roots, an axialimpact may force the apex of the root through the thinlabial cortical bone plate."-''-'^ Gentle palpation in tbisarea helps to determine whether or not the root tip haspenetrated the thin labial cortical plate. ''™ In tbe initialclinical examination, pbotograpbs may be indicated forlegal records.---' -I*

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GRADE

Fig 3a (ßbove) Severe int'usion of tooth 61. The toothis completely intruded into the socket. Note theswelling and redness of the gingiva.

Fig 3b ¡I'ight) Ooclusal radiograph showing a labialintrusion o( tooth 61 away from the germ of its perma-nent successor The labially intruded incisor movescloser lo the x-ray source and appears foreshortenedon the radiographie image.

Fig 4a (above) Complete intrusion o' tooth 51 ihis26-month-cid child teii irom his bed at home. The gingi-val and mucosai tissues are swoiien, red, and painful.

Fig 4b (right) Periapicai radiograph showing severeintrusive displaoement of the intruded tooth 51, whichinvaded the permanent tooth germ.

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Radiographic examination

Radiographs are an important baseline test in the caseof traumatic injuries. They help in detecting hone androot fractures; evaluating the root development stage,the size and the state of the pulp, and the relationshipwith the permanent tooth germ; and determining thepresence of foreign bodies in soft tissues.-'••'^•''^Periapical and occlusal radiographs are adequate todiagnose an intruded incisor, whieh will appear sub-merged in the bone with absence of periodontal liga-ment space (Fig 5). The possibility of detecting theintrusion increases from SO /o when only an occlusalradiograph is taken to 9P/o when both occlusal andperiapical radiographs are taken.•'

The occlusal image determines the direction of theintrusion (labial or palatal) by evaluating the dimen-sion of the intruded incisor.--'-''-'- ' A palatally intrudedprimary incisor that invaded the germ of its succeda-neous permanent tooth moves away from, the x-raysource and appears eiongated on the radiographieimage (see Fig 2b). Conversely, a labially intruded pri-mary incisor that displaced away from the developinggerm moves closer to the x-ray source and appearsforeshortened on the radiographie image ''' - ^ (seeFig 3b).

In addition, an extraoral anterolateral exposurehelps in determining the exact position of the intrudedprimary incisor and shows whether or not the rootapex has pierced the labial cortical plate and the prox-imity of the intruded incisor to the succeeding perma-nent incisor.^''''''^''^ This view can be taken by tapingan occlusal ñlm onto the child's cheek.--" The x-raybeam is directed from the opposite side of the faceperpendicular to the film, and the exposure time isdoubled from the normal periapical exposure time. ^

MANAGEMENT OF INTRUSION INJURIES

Management of an intruded primary incisor dependson many variables, such as the direction and severityof the intrusion and the presence oí alveolar bonefracture. As mentioned earlier, appropriate diagnosticmeasures should be taken to ascertain the relationshipbetween the intruded incisor and the developing toothgerm.

The orientation of the intrusion influences the man-agement decision. Frequently, because of its labial cur-vature, the root of the primary incisor becomes forcedthrough the labial bone away from the permanenttooth germ.^'^'äJ in this case, spontaneous reeruption isanticipated within 1 to 6 months^"'^^^-^'-^"''"«'^**^'"-"(see Figs 1 and 5). Pulpal necrosis and/or pathologicroot résorption are common because of the marked

Fig 5 Same-day occlusal radiograph oí a traumatio in|ury to a22-month-oid boy alter a laii, showing a miid (grade I) intrusion oftootri61.

injury to the pulpal tissue and the periapical struc-tures." To minimize the possibility of such complica-tions, some authors advocate prescribing a 1-weekcourse of antibiotic therapy such as penicillin or ery-

An experimental study in monkeys has shown thatextraction of the intruded incisor results in less dam-age to the traumatized enamel epithelium of the per-manent successors." With removal of the intrudedtooth, the influence of subsequent intramedullarychronic inflammation is eliminated, reducing the pos-sibiiity of further damage to the permanent toothgerm. * However, application of these histologie find-ings to the clinical finding was not justified."

Other investigations have found no significant dif-ference in the frequency or extent of developmentaldisturbances of the permanent successors, irrespectiveof whether the intruded tooth is extracted or allowedto reerupt.'i't'^ä Ravn^' reported that 52% of thereerupted intruded incisors induced disturbances intheir successors, compared with 72% of the extractedintruded incisors. This indicates that injury to the per-manent tooth germ is sustained at the time of theactual intrusion.^'-'^

Less frequently, an impact directed toward the lin-gual surface of the crown forces the root palatally,resulting in possible contact with or invasion of thefollicle zone of the permanent tooth and encroach-ment on the developing permanent germ- ' ' ' - o.ei(see Figs 2 and 4). In this case, the preferred treatmentwould be careful removal of the tooth to relieve thepressure on the odontogenic tissues within the devel-oping follicle.22-35".«.46,5o,53,62

In addition to orientation, the degree of intrusionplays an important role in deciding the appropriatemanagement. Spontaneous reeruption is anticipatedwhen the intrusion is mild (grade I or less than 50% of

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Fig 6 Spontaneous reeruption vi-as anticipated for the intruded pri-mary incisor, tooth 61 The tooth became ankylosed and the childwas suffering from pain Note the gingival inffammation around theankylosed, intruded tooth. The offered treatment v as extraction.

the crown length)."'^"'^^ Whenever the intrusion ismoderate or severe (grades II and III, or more than50% of the crown length), the tooth rarely reeruptsand may become necrotic, indicating tbe need forextractions^"^^''''•" (see Fig 4). Furthermore, a severeintrusion impact may lead to perforation of the buccalcortical plate by tbe root apex of tbe intruded tooth.Likewise, tbe intruded primary incisor may becomeentirely positioned buccal to the cortical plate witbinthe soft tissues of tbe mucobuccal fold. In both cases,extraction of the intruded tooth should be consid-g j ' e J 22.35,49,51-53,62

The presence of an alveolar bone fracture is alsocrucial in the decision on how to manage intrusion. Ina study by Borum and Andreasen,^ 54.5% of theintruded primary incisors were accompanied by frac-ture of the socket walls at the time of injury. Tbeintruded incisors failed to reerupt more frequentlywhen bone fracture was present.' Tbe fractured corti-cal bony plate should be repositioned immediatelywitb gentle digital manipulation and tbe intrudedtootb sbould be extracted.^"-^' Otber mobile teetbshould be repositioned and possibly splinted."'"^

In tbe case of socket bone fracture, tbe issue ofsplinting tbe luxated primary incisors is controversial.Some autbors support the idea that primary incisorsdo not require splinting because of several factors,such as the rapid healing of bone in children, lack ofpatient cooperation, and avoiding further discomfortto the child.- ' "' ' Other authors advocate splinting themobile teetb to allow tbeir restabilization and healingof the bone, wbich occurs in 3 to 6 weeks.''*'*

In patients of this age, the options for splint selec-tion are somewhat limited, and a simple splint, such asthe nonrigid, acid-etched resin composite splint,should be considered. Tbe composite material can beapplied between the mesial and distal surfaces of theincisors or applied to tbe incisai half of the labial sur-

faces with or without a monofilamen' fiSembedded in the resin composite.^^^ " ' ^option would be a cold-cure resin splint, \V1Í¡L!I can Demolded over tbe incisai edges of tbe incisors.""'

If observation has been elected as a strategy to waitfor spontaneous reeruption, it sbould be noted tbatfailure of reeruption is possible.''••"•'' If signs of reerup-tion are not evident after 4 to 8 weeks, this may indi-cate ankylosis of the intruded tootb, and extractionshould be considered ''ä.='t.2e.j3.56,64 (pjg ^y ^ child witha digit and thumb babit may apply a pressure, prevent-ing the intruded teetb from reeruption.^^" In addition,if tbe tootb was Intruded witb a rotated orientation, itmay reerupt at the same rotated angle and create acrossbite or traumatic occlusion. ='•••'"'•"

Anotber possible complication is an acute inflam-mation around tbe intruded tooth (Fig 6) or even acellulitis. These result from a bacterial infection at thesite of trauma, wbicb induces swelling of the gingiva,spontaneous bleeding, pain, malaise, and fever. ' ' ""In tbe long term, a cbronic abscess may form, generat-ing a purulent exúdate erupting from a fistula.^^"-" Inafl tbese cases, extraction is recommended, along witbantibiotic tberapy to prevent spread of inflammationto tbe permanent tootb germ. - ' ' Furtbermore, evenwitb complete spontaneous reeruption, the tootb maysuffer pulpal necrosis at some point, and the appropri-ate treatment would be extraction.-^"

Parents will frequently inquire about the possibilityof damage to the permanent tootb. The dentist shouldbe cautious in making these predictions. If the circum-stances of the injury are such that the primary root Ispushed toward the permanent tooth germ, any resultingdamage will have occurred at impact. Consequently,tberapy, including extraction of the primary tooth, willnot prevent damage to the underlying permanent tooth.

RECOMMENDATIONS TO PARENTS

After a traumatic injury, some recommendationsshould be given to the parents, such as maintainingthe cbild's fluid intake and a soft diet for a few daysafter the injury.sö''^ Tbe traumatized area can becleaned by wiping the injured teetb and the soft tissueswith a swab dipped in an alcohol-free moutbwasb.^*Wben reeruption of the intruded incisor is expected,tbe parents should pay particular attention to develop-ment of signs and symptoms such as swelling of thesurrounding gingival tissues, redness, pain, purulentexúdate, and systemic symptoms sucb as fever. If anyof tbe aforementioned signs is noticed, the parentssbould contact tbe treating dentist immediately. Inaddition, parents sbould make appointments for peri-odic follow-up examinations.

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FOLLOW-UP

Careful follow-up of intrusion injuries of primary teethis very important. The frequency and extent of the visitsdepends on the type and severity of the injury. Recallexaminations would detect any complications relatedto the intruded tooth, which consequently may inducedamage to the developing permanent tooth. A firstpostinjury assessment should be undertaken 7 daysafter the injury.-' -' Recall examinations can be per-formed regularly every 2 weeks during tbe first month,then every month for the first 5 months, and then every6 months,^'' At each visit, a complete examinationshould be done to look for the presence of any unusualsymptoms, for instance, spontaneous pain, malaise,fever, signs of abscess such as fistula, and swelling ofthe gingiva and the surrounding soft tissues.^"''''

The progress of reeruption and repositioning shouldbe evaluated. Lack of reeruption movement andabsence of physiologic mobility may indicate ankylo-sis. Any discoloration of the recrupted primary incisorshould be noted. Yellow discoloration may indicateinternal calcification, and black discoloration could bean indication of pulpal necrosis. In addition, a radio-grapb sbould be taken 1 to 2 months after the injuryto discern any periapical radiolucency, pulpal calcifi-cation, or external or internal root resorption.^^ If anyof these chnical and/or radiologie complications isevident, extraction of the primary intruded incisorshould be considered.

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