Crown dilaceration of permanent central incisor as a result of

Nawal RR et al
IJRD
ISSUE 3, 2014
CASE REPORT
Crown dilaceration of permanent central
incisor as a result of different etiologic
factors ˗ a report of three cases
Ruchika Roongta Nawal*, Shivani Utneja**, Sanjay Chhabra ***, Sangeeta Talwar#, Mahesh Verma##
* Assistant Professor, Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences,
Bahadurshah Zafar Marg, New Delhi: 110002. ** Senior Research Associate, Conservative Dentistry and
Endodontics, Maulana Azad Institute of Dental Sciences, Bahadurshah Zafar Marg, New Delhi: 110002. *** Dental
Officer, Conservative Dentistry and Endodontics, Army Dental Centre (R & R), Delhi Cantt, New Delhi 110002.
# Professor and Head of Department, Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental
Sciences, Bahadurshah Zafar Marg, New Delhi: 110002. ## Director-Principal and Head of Department,
Prosthodontics, Maulana Azad Institute of Dental Sciences, Bahadurshah Zafar Marg, New Delhi: 110002.
Address for correspondence: Dr Shivani Utneja M.D.S., Senior Research Associate, Conservative Dentistry and Endodontics, Maulana
Azad Institute of Dental Sciences, Bahadurshah Zafar Marg, New Delhi: 110002.
Mob: +919711459961 Fax: +91-1-23217081
Email: [email protected]
Abstract : Two possible causes of crown dilaceration are trauma and developmental disturbances, and it has also been proposed that
it might be associated with some developmental syndromes. This article details the diagnosis and describes the alterations in endodontic
treatment procedures while managing crown dilaceration in maxillary central incisor. Diagnosis, endodontic access cavity preparation,
root canal preparation and obturation, and other related treatments might be complicated by the presence of crown dilaceration. The
present case series reports three cases of crown dilaceration in permanent central incisors having varied etiology.
Keywords: dental anomaly, developmental disorder, trauma.
trauma to the primary predecessor tooth leading to
dilaceration
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of
the
developing
succedaneous
permanent tooth. This anomaly constitutes 3% of all
primary tooth injuries (2).The trauma usually
INTRODUCTION
Dilaceration is an angulation or a sharp bend or
responsible for this type of lesion is frequent
traumatic intrusion or avulsion during childhood
curve in the root or crown of a developed tooth of
between the ages of 1-5 years (1,3).Other alterations
90° or more (Latin: dilacero = tear up). Angulated
in dental pathology produced by intrusion of
crown or crown dilaceration is the displacement of a
primary teeth include, white or yellow-brown
portion of the developing crown of a tooth at an
discoloration, or circular enamel hypoplasia, root
angle to the longitudinal axis of the tooth (1). The
duplication, vestibular or lateral root angulation or
most widely accepted cause for this is mechanical
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dilacerations, partial or complete arrest of root
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Nawal RR et al
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ISSUE 3, 2014
formation, sequestration of the permanent tooth resulted in intrusion of his primary incisors. Medical
germ and disturbed eruption (4). The severity of the
history of the patient was non-contributory. On
lesion on a permanent tooth depends on the
clinical examination, the permanent maxillary right
developmental stage of the tooth, the force of
central incisor showed crown dilaceration with the
impaction and the direction of force applied with
labial surface displaced palatally in the incisal third
respect to the permanent tooth (5).
of the crown giving the appearance of short crown
Crown dilaceration usually involves the maxillary
length (Fig 1a, 1b). A notch was evident in the
incisors and, less frequently, the mandibular
incisal edge and there was a characteristic midline
incisors, because they are in close contact with the
diastema (Fig 1a). Percussion test was positive in
primary incisors and are more prone to injury (6). In
relation to both right upper central and lateral
about half of these incidents, impaction occurs while
incisor. An intraoral periapical radiograph of the
there is normal eruption in lingual or vestibular sites
tooth revealed periapical pathology in relation to 11
in the remaining cases. Clinically, the maxillary
and 12 .The radiograph also revealed a bend in the
incisors show a lingual deviation while the
crown of 11 at the level of cemento enamel junction,
mandibular incisors incline facially (4).
giving the appearance of foreshortening coronally
Some recent studies also suggest dilaceration to be a
(Fig 1c). Electric pulp testing gave no response for
true developmental anomaly that is not related to a
both these teeth indiacting non-vitality. Endodontic
history of trauma (1, 7-9). Jamal et al. (10) have
treatment was decided as the treatment plan for both
emphasized the relation of cleft lip and / or palate to
11 and 12. Conventional palatal access was obtained
all dental anomalies studied and reported that 19.2%
under rubber dam isolation, the working length was
of their subjects of cleft lip and palate had
determined using an electronic apex locator (Root
dilacerations. However, there are comparatively
ZX; J Morita Corporation, Japan) and confirmed
fewer case reports that suggest developmental
with
disorders to be related to the etiology of crown
preparation was done using hand K Flex files
dilaceration.
(Dentsply Maillefer, Switzerland) to an apical size
The purpose of this paper is to report cases of crown
of # 45 in 11 and #40 in 12 using step back
dilaceration, related to both traumatic injury to the
technique.
primary predecessor and associated underlying
encountered while preparing 11 owing to palatal
developmental disorder.
displacement of the incisal third of the tooth.
Case report 1
Calcium
A 22-year old male reported to our department with
medicament for two weeks. Obturation was done
the chief complaint of small sized upper front tooth
with gutta percha cones (Dentsply Maillefer,
with occasional pain in that tooth since 15 days. A
Switzerland) and AH Plus sealer (Dentsply) using a
detailed trauma history of the patient revealed that
lateral condensation technique (Fig 1e). Labial
he injured his maxillary primary central incisors due
contouring of 11 was carried out with light cured
to a fall when he was two years old. This episode
composite resin (Filtek Z350;3M ESPE, St Paul
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a
radiograph
Difficulty
Hydroxide
(Fig
in
used
1d).
Biomechanical
instrumentation
as
an
was
intracanal
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Nawal RR et al
IJRD
ISSUE 3, 2014
[MN] USA). An esthetically pleasing result was distal caries in the crown of 21 (Fig 2 a). Intraoral
obtained with composite restoration (Fig 1f). The
periapical radiograph of the tooth showed close
patient was recalled after six months to assess the
approximation of distal caries to the pulp .It also
periapical status of the tooth. Considerable healing
revealed the presence of crown dilaceration in the
was evident on the periapical radiograph and the
same tooth at the cervical level (Fig 2b). Electric
patient was asymptomatic (Fig 1g).
pulptest of 21 gave an early response indicative of
irreversible pulpitis. Root canal therapy was decided
as the line of treatment for the dilacerated tooth
followed by esthetic restoration. Coronal shaping of
the root was done using Gates Glidden drill (#4-#2)
(MANI Inc., Tochigi City, Japan) for obtaining a
straight line access and bypass the dilacerated
portion of the tooth. Glide path was obtained using a
#20 K Flex file (Dentsply Maillefer, Ballaigues,
Switzerland). After determination of the working
length (Fig 2c), biomechnaical preparation was
completed using Protaper rotary instruments till F4.
Figure 1a: Intraoral view showing palatal inclination of the
permanent maxillary right central incisor giving
appearance of short crown length. Figure 1b: Preoperative
occlusal mirror image of dilacerated maxillary right
central incisor. Figure 1c: Intraoral periapical radiograph
revealing a foreshortened crown of 11 with periradicular
radiolucency in 11 and 12. Figure 1d: Working length
radiograph. Figure 1e: Intraoral periapical radiograph
after obturation. Figure 1f: Postoperative photograph after
composite buildup. Figure 1g: Follow up intraoral
periapical radiograph after six months showing resolution
of periradicular radiolucency.
Obturation of the root canal was done with Protaper
gutta percha and AH Plus sealer (Fig 2d).
Post
obturation restoration was done using light cure
microhybrid composite restoration (Filtek Z350;3M
ESPE, St Paul [MN] USA) after one week (Fig 2e ).
At a six month recall, the patient was asymptomatic
and undergoing his orthodontic treatment.
Case report 2
A 12-year- old boy was referred to our department
with the chief complaint of
spontaneous but
intermittent pain for last one month in his upper left
central incisor. The patient was affected with
unilateral cleft lip and palate of the left side and was
undergoing orthodontic treatment for the correction
of associated malocclusion. Surgical repair of cleft
lip and palate was performed for him between the
age of 6 to 18 months. Medical history of the patient
was insignificant. Clinical evaluation revealed deep
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Figure 2a: Preoperative photograph showing deep distal caries in
permanent maxillary left central incisor. Figure 2b: Intraoral
periapical radiograph showing close approximation of distal
caries to pulp and presence of crown dilaceration at cervical level
in 21. Figure 2c: Working length radiograph of 21. Figure 2d:
Postobturation radiograph of 21. Figure 2e: Postoperative
photograph of 21 showing esthetic composite restoration
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Nawal RR et al
Case report 3
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ISSUE 3, 2014
test of this tooth revealed an early response
A 15 year old female who was a diagnosed case of
indicative of inflamed pulp. Routine access opening
Amelogenesis Imperfecta- hypocalcified type was
was performed and glide path determined using a
referred to our department from the Oral diagnosis
#15 K-flex file. The access cavity was enlarged
department for her chief complaint of extreme
mesially to gain straight-line access to the root apex.
sensitivity to hot and cold, poor masticatory
Biomechanical preparation was performed by crown
efficiency and dissatisfaction with the appearance of
down manner till MAF #70. Obturation was done by
her teeth. A detailed medical, dental, and social
step back technique using 2% Gutta-percha cones
history was obtained. Clinical examination of the
and AH Plus sealer (Fig 3f). The access cavity was
patient revealed hypocalcified enamel, marginal
sealed with composite after one week.
gingivitis, improper intercuspation and lack of
proximal contact because of tooth surfaces loss.
There was generalized attrition resulting in short
clinical crowns and marked loss of occlusal vertical
dimension. Tissue loss affected all the teeth, the
enamel was barely visible and appeared soft, friable
and yellow brown in color. The cuspal structure was
completely absent in the occlusal portion of the
molars. The exposed dentin was hypersensitive. The
patient exhibited poor oral hygiene and presented
hyperemic and edematous gingiva. A mesiodens was
present between 11 and 21.15, 16, 34, 35, 36, 37 and
47 had proximal caries (Fig 3a, 3b and 3c). CBCT
scan showed severe close pulp approximation with
all the teeth (Fig 3d). Another significant finding
observed on radiographic examination was crown
dilaceration of 11(Fig 3e). The treatment plan
decided comprised of four phases. The first phase
consisted of oral prophylaxis. Endodontic treatment
of all the teeth was planned in the second phase of
treatment. In the third phase of treatment periodontal
surgery was designed. Following this the patient
would
be
referred
to
the
department
of
prosthodontics for occlusal rehabilitation .
For the purpose of this paper, we would focus on the
Figure 3a: The occlusal view of maxillary arch. Figure
3b:The occlusal view of mandibular arch. Figure 3c:
Clinical appearance of Amelogenesis Imperfecta.
Pretreatment labial view of maxillary and mandibular
teeth. Figure 3d: Pretreatment CBCT scan. Figure 3e:
Pretreatment intraoral periapical radiograph showing
dilacerated permanent maxillary right central incisor.
Figure 3f: Postobturation radiograph
DISCUSSION
Crown
dilaceration
is
termed
a
non-axial
displacement of already formed hard tissue in
relation to developing odontogenic tissues (4). The
condition is thought to be due to trauma occurring
when the tooth is forming, which alters the position
of the calcified portion of the tooth so that the
remainder of the tooth is formed at an angle.
Trauma alone is unlikely to account for all cases of
dialceration
(11).
Idiopathic
developmental
disturbances are proposed as another possible cause
in cases that have no clear evidence of traumatic
diagnosis and treatment of dilacerated 11. Vitality
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Nawal RR et al
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injury (1,4,9). Facial clefting is considered to be one The other two cases reported here also exhibited
of the many contributing factors and it has also been
clinical and radiographic features in accordance with
proposed that it might be associated with some
the earlier reports on teeth with crown dilacerations
developmental syndromes (10,11). Stewart (7)
(13,14). Treatment options for crown dilacerations
investigated 41 cases of dilacerated incisors and
include (5):
found that trauma accounted for only 22% . In two
1. Surgical
exposure
with
or
without
orthodontic realignment
other case reports of dilacerated teeth in the
mandible, no history of trauma to the lower labial
2. Removal of dilacerated part of crown
segment was found (8.12). In the cases presented
3. Temporary crown until root formation is
complete
here, the etiology of dilaceration was varied. In the
first case report, dilaceration in the crown of
4. Semi or permanent restoration
permanent maxillary right central incisor was a
5. Prosthesis or orthodontic space closure
following extraction
result of traumatic injury to the primary predecessor
tooth, while in the other two cases it was associated
In
the
present
with developmental anomalies like cleft lip and
endodontic therapy of the involved tooth
palate and amelogenesis imperfecta respectively.
followed by labial contouring with composite
Histologically, the enamel epithelium gets displaced
restoration.
along with the mineralized portion of the tooth in
procedure with calcium hydroxide helped in
relation to the dental papilla and cervical loopes.
resolution of the periapical pathology. In the
This results in the loss of facial surface enamel
second case presented here the patient was
while on the lingual side a cone of hard tissue is
referred back to the department of orthodontics
formed that projects into the root canal (4).
for the management of malocclusion associated
Brownish discoloration is caused by disturbances in
with cleft lip and palate after completion of
the ameloblastic layer, leading to defective matrix
endodontic therapy of dilacerated central incisor.
formation. The stretched inner enamel epithelium
The third case reported here was a diagnosed
continues to induce the differentiation of new
case of Amelogenesis Imperfecta who is
odontoblast, hence the dentin formation is not
undergoing intentional endodontic treatment of
affected. Pulp necrosis and periapical inflammation
the remaining teeth
of these teeth without any decay may be a common
treatment of her dilacerated incisor.
finding. This is because the bent portion with a
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How to cite this article:
Nawal RR, Utneja S, Chhabra S, Talwar S,
Verma M. Crown dilaceration of permanent
central incisor as a result of different
etiologic factors ˗ a report of three cases.
IJRD 2014;3(3):72-77.
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