Avulsion of primary teeth and sequelae bjdt v2n2a05 by Alexandre

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AVULSION OF PRIMARY TEETH AND SEQUELAE ON THE PERMANENT SUCCESSORS: LONGITUDINAL STUDY Michele Machado Lenzi1 , Diana Ribeiro Jacomo2 , Vivian Carvalho1 and Vera Campos3 Received on March 16, 2011 / Accepted on April 15, 2011

ABSTRACT The aim of this study was to determine the frequency of the avulsion in primary anterior teeth and the frequency and the type of developmental disturbance in the permanent successors teeth in accordance with the patient age at the time of trauma. Data from dental records of 307 children with ages varying from 0 to 10 years were analyzed. All patients presented signs of trauma on anterior teeth and came to the Dental Trauma Center of the Pediatric Dentistry Clinic of Rio de Janeiro State University (UERJ) during the period of March 1996 to December 2004. The sample was made up of 753 anterior deciduous teeth with trauma, of which 106 (14.1%) had avulsion. The age group with the highest frequency of avulsion was the 2-4 years of age and the main etiological factor was falls. Thirty-two successor teeth out of the 106 avulsioned deciduous ones were clinically and radiographically controlled until complete eruption. Out of the 32 successors, 20 (62.5%) presented sequelae. Results showed that avulsion was the second most frequent type of trauma in primary dentition and discoloration of enamel and/or enamel hypoplasia were the most frequent sequelae in the successors. The biggest number of sequelae occurred when avulsion happened to 2-3 year-old children. Keywords: avulsion, primary tooth, tooth injury.

Correspondence to: Michele Lenzi Preventive and Community Dentistry Department, College of Dentistry, Rio de Janeiro State University, Boulevard 28 de Setembro, 157, sl. 226, Vila Isabel, 20511-030 Rio de Janeiro, RJ, Brazil. Phone: +55 21 2587-6372 – E-mail: michelelenzi@hotmail.com 1 MSc student in Pediatric Dentistry, Rio de Janeiro State University, Brazil. 2 MSc in Pediatric Dentistry, Rio de Janeiro State University, Brazil. 3 Preventive and Community Dentistry Department, Pediatric Dentistry, Rio de Janeiro State University, Brazil.

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MICHELE MACHADO LENZI, DIANA RIBEIRO JACOMO, VIVIAN CARVALHO and VERA CAMPOS

INTRODUCTION Traumatic dental injuries are frequent during childhood with a frequency that varies from 4 to 30% [1-5]. The most frequent types of dental traumas in primary teeth are intrusion and avulsion [6-13]. The maxillary teeth in both primary and permanent are most affected by trauma, especially the central incisors due to its position [4, 5, 12, 14-18]. Most injuries occur at home or around and falls are the main cause followed by accidents in sports and physical aggression [2, 7-9, 19]. Developmental disturbances in permanent teeth caused by trauma in their predecessors have a frequency that ranges from 12-74% [8-10, 16, 17, 20-22]. This high frequency is due mainly to the close anatomical relationship between the apices of primary teeth and their developmental permanent successors [9, 10, 14, 21]. The aim of this study was to determine the frequency of the avulsion in primary anterior teeth and the frequency and the type of developmental disturbance in the permanent successor’s teeth in accordance with the patient age at the time of trauma. MATERIAL AND METHODS This is a retrospective study undertaken with the approval of the Ethics Committee of the Pedro Ernesto University Hospital (HUPE) and with the consent of the parents or caretakers, who signed documental authorizations. Data from dental records of 307 children (169 boys and 138 girls) with ages varying from 0 to 10 years were analyzed. All patients presented signs of trauma on anterior primary teeth (incisors and canines) and came to the Dental Trauma Center of the Pediatric Dentistry Clinic of Rio de Janeiro State University (UERJ) during the period of March 1996 to December 2004. Records provided personal data regarding the children, such as name, address, age and gender and also contained information on their trauma history, the etiology, place, type of injury, date, sequelae and recall examinations in accordance with the World Health Organization classification of injury types modified by Andreasen & Andreasen [14]. Children were examined for by Pediatric Dentistry graduate students previously trained and supervised by the same professor of the Pediatric Dentistry Clinic. Sequelae in permanent teeth were (in decreasing order of severity): sequestration of permanent tooth germ, odontoma-like malformation, partial or complete arrest of root formation, crown dilacerations, root dilacerations, root duplication, discoloration of enamel and/or hypoplasia and erupation disturbances [8]. Discoloration of ena-

Brazilian Journal of Dental Traumatology, Vol. 2(2), 2011

mel and hypoplasia were considered together because both sequelae occur during the amelogenesis [9]. In cases in which the same tooth presented more than one sequelae only the more severe is considered. Clinical and radiographic follow up of the patients were conducted weekly, monthly, etc, according to severity and type of injury. The results were statistically analyzed using SPSS (S˜ao Paulo, SP, Brazil) 8.0 software. Chi-squared tests were used to determine significant differences in data ( P < 0.05). RESULTS In the 753 traumatized primary anterior teeth, intrusion was the most frequent cause of trauma (29.3%, n = 221), followed by avulsion (14.1%, n = 106) (Fig. 1). The age group with highest frequency of avulsion is 2-4 years of age. It happened to boys (59.4%, n = 63) more than to girls (40.5%, n = 43). The result is not statistically meaningful at the 5% level ( p < 1,00). The most often named causes were fall from a high surface (40.3%), followed by fall from one’s own height (36.8%) and falls on hard surfaces (22.80%). The maxillary primary incisors were the teeth that suffered the most from avulsion. The most frequent was 61 (37.7%), followed by 51 (35.8%) and 52 (10.4%). The difference between the two was not statistically meaningful at the 5% level ( p < 1.00) (Table 1). Table 1 – Distribution of avulsed teeth.

Tooth, FDI system

FDI, Federation Dentaire Internationale.

Thirty-two successors of the 106 avulsioned primary teeth were clinically and radiographically controlled until complete eruption. Twenty were not controlled because they had not yet erupted and 54 because the patients gave up. Twenty out of the 32 successors (62.5%) presented sequelae. The most frequent ones were alteration of color and/or hypoplasia of the enamel (45%, n = 9), alteration of eruption (25%, n = 5) and dilaceration of the crown (15%, n = 3). Sequelae in successors were more frequent when the trauma to the primary tooth happened in patients in the age group of 2-3 yearolds (35%) (Table 2). However, it was not possible to establish a connection between the kind of trauma to the deciduous dentition and the kind of sequelae in the permanent successors.

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n = 753 anterior deciduous teeth injured

Figure 1 – Frequency of injury types on anterior deciduous teeth during the period of March 1996 to December 2004.

Table 2 – Types of developmental disturbances in different age groups.

Discolouration + enamel hypoplasia (NO) 0-1 year 1-2 year 2-3 year 3-4 year 4-5 year 5-6 year 6-7 year 7-8 year 8-9 year 9-10 year

Crown dilaceration

Root dilaceration

Sequestration of the permanent tooth germ 1

Eruption disturbances 1

1 1 2 1

DISCUSSION In this study, the frequency of avulsion in primary dentition was 14.1%. That figure is compatible with the ones researched in the literature, whose variation is 0.8-38% [4, 6, 9, 12, 14-16, 19]. Those differences can be attributed to the different methods of research and data collection. For some authors, there is no statistically significant difference between the genders as far as the occurrence of dental trauma is concerned [7, 8, 14]. However, other authors show higher frequency among boys [2, 4, 16]. In this research, males (59.4%) suffered more than females (40.5%), a result that was not statistically significant at the 5% level ( p < 1.00).

1 1 1

As far as etiology of dental trauma is concerned, falls were the most common cause of avulsion, which is in accordance with most of the researched studies [2-4, 7-9, 11, 18, 19, 23]. The literature shows that maxillary primary central incisors are the most affected teeth and that there is no significant difference between the right and the left sides [2, 4, 6, 8, 18]. Nonetheless, for Andreasen and Andreasen [14], Christophersen et al. [15] and Ravn [17], the right superior deciduous central incisor is the tooth that is affected by avulsions the most. The results of this study showed that tooth 61 was the most affected by avulsion, followed by 51 and 52, although the difference between both was statistically significant at the 5% level ( p < 1,00).

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MICHELE MACHADO LENZI, DIANA RIBEIRO JACOMO, VIVIAN CARVALHO and VERA CAMPOS

Trauma to deciduous dentition can affect successors due to the proximity between the apices of primary teeth and the germs of permanent ones [9, 17, 20]. The frequency of sequelae in permanent teeth after avulsion in primary ones varies from 12 to 74% [8-10, 16, 17, 20-22]. Christophersen et al. [15] found a frequency of 30%, Von Arx [9] of 52% and Ravn [17] of 74%. In this research, the frequency of sequelae in permanent successor teeth was 62.5% which is in accordance with the researched studies. However it should consider the fact that there was considerable desistance by patients in control appointments, which made it impossible to monitor 74 successors until complete eruption. When the age of the child at the time of the trauma is measured against the frequency of sequelae in successor teeth, the results of researched pieces of work showed that the younger the child is at the time of the trauma, the bigger is the chance of there being sequelae [9, 10, 17, 20, 24]. According to the results found in this study, the most teeth with sequelae occurred when the child was 2-3 years old at the time of the trauma. That result corroborates the studies of Ravn [17] and Christophersen et al. [15], which proved that the germ of the permanent tooth is more likely to suffer trauma in the initial stages of its development. There is, however, the possibility of sequelae from trauma in primary teeth that takes place after the complete formation of the crown of permanent teeth. That is due to secondary enamel mineralization which remains during the initial stages of radicular formation [9, 15, 17, 20]. In this study, the most frequent sequelae were discoloration of enamel and/or enamel hypoplasia (45%), followed by disturbances of eruption (25%) and dilaceration of the crown (15%). The discoloration of enamel affects the successor permanent tooth of chidren in the 2-7 year-old age group [9, 17, 21]. In avulsion, the primary tooth can affect the development of the permanent tooth mechanically due to the anatomical proximity between the apex of the primary tooth and the germ of the permanent one, thereby interfering in the mineralization of the enamel. As a consequence in the successors, it is possible to observe clinically white spots due to the loss of mineral or brownish-yellow spots due to the diffusion of substances that are present in the blood where the enamel is formed [9, 14]. The studies herein researched also showed that the discoloration of enamel and/or enamel hypoplasia of the are the sequelae that affect successor teeth the most [1, 8, 10, 15, 20]. After the avulsion of primary tooth, the recall examinations have, by means of clinical and radiographical exams, the objective of preventing or diagnosing further consequences to the germ of the developing successor [8, 11, 25]. Treatment in avulsion cases requires detailed study of dental development and collaboration from the child for the eventual recommendation of devices to maintain space [26-29].

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In this research, collection of data was carried out by means of dental records. It is, therefore, a retrospective study. In this kind of study, control of the traumatized element and periodical follow-up of the child after the trauma are of utmost importance. CONCLUSIONS 1 - Avulsion was the second most frequent type of trauma in primary dentition. 2 - Discoloration of enamel and/or enamel hypoplasia were the most frequent sequelae in successors. The most sequelae occurred when avulsion happened in 2-3 year-old children. 3 - Follow up is very important to diagnose problems as soon as possible to plan long term management. REFERENCES [1] Andreasen JO, Sundstrom B & Ravn JJ. 1971. The effects 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, 79: 219–83. [2] Ortiz Scarpari CE, Possobon RF & Morais ABA. 2004. Ocorrência de traumatismos em dentes dec´ıduos de crianças atendidas no Cepae Fop-Unicamp. Rev Ibero-am Odontopediatr Odontol Bebê, 35: 33–40. [3] Bastone EB, Freer TJ & McNamara JR. 2002. Epidemiology of dental trauma: a review of the literature. Aust Dent J, 45: 2–9. [4] Kramer PF, Zembruski C, Ferreira SH & Feldens CA. 2003. Traumatic dental injuries in Brazilian preschool children. Dental Traumatol, 19: 229–303. [5] Oliveira LB, Marcenes W, Ardenghi TM, Sheiham A & Bonecker M. 2007. Traumatic dental injuries and associated factors among Brazilian preschool children. Dental Traumatol, 23: 76–81. [6] Soporowski NJ, Allred EN & Needleman HL. 1994. Luxation injuries of primary anterior teeth – prognosis and related correlates. Pediatr Dent, 16: 96–101. [7] Diab M & Elbadrawy HE. 2000. Intrusion injuries of primary incisors. Part I. Review and management. Quintessence Int, 31: 327–34. [8] Jacomo DRES & Campos V. 2009. Prevalence of sequelae in the permanent anterior teeth after trauma in their predecessors: a longitudinal study of 8 years. Dent Traumatol, 25: 300–4. [9] Von Arx T. 1993. Developmental disturbances of permanent teeth following trauma to the primary dentition. Aust Dent J, 38: 1–10. [10] Ben-Bassat Y, Brin I, Fuks A & Zilberman Y. 1985. Effect of trauma to the primary incisors on permanent successors in different developmental stages. Pediatr Dent, 7: 37–40. [11] Alexandre GC, Campos V & Oliveira BH. 2000. Luxaçaõ intrusiva de dentes dec´ıduos. Rev Assoc Paul Cir Dent, 54: 215–19.

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