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Case Report Endodontic and orthodontic interdisciplinary

management of a patient with Turner’s
hypoplasia
 Gaurangi Lavania, Anuj Lavania1
Department of Conservative Dentistry and Endodontics, 1Department of Orthodontics and Dentofacial Orthopaedics
NIMS Dental College, Jaipur, Rajasthan, India

Address for correspondence: Dr. Gaurangi Lavania, E‑mail: kakodkargaurangi@gmail.com

ABSTRACT
Trauma to primary dentition usually presents with problems in the permanent dentition which are difficult to treat. This case
report describes the treatment of a 23‑year‑old adult female patient with crown dilaceration and discoloration of maxillary
right central incisor. Therapeutic management of this tooth was combined with orthodontic treatment for proclination due
to associated dilaceration of crown. A sequential approach of endodontic treatment followed by orthodontic treatment was
carried out. The tooth was later treated with a fiber post, and ceramic facing crown was delivered. To produce esthetic results,
discoloration of maxillary left central incisor was treated with the composite restoration.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

• The article “Endodontic and Orthodontic Interdisciplinary Management of a Patient with Turner’s Hypoplasia” is a case
report of a young 23‑year‑old girl who was seeking dental help for her unesthetic upper incisors
• The proclination due to an unusual crown angulation could not be corrected by prosthetic treatment alone and required
help from an orthodontist. Once the proclination along with crowding was corrected, the esthetics could be improved
• Also the patient had focal hypoplastic lesions with brownish discoloration and root reinforcement was required. Thus, a
fiber post was luted
• The esthetic look was, however, enhanced with a prosthetic treatment of a metal ceramic crown.

Key words: Anterior tooth trauma, hypoplasia, turner's hypoplasia

INTRODUCTION focal areas or may involve the entire crown. It is

most common in permanent maxillary incisors or

H ypoplasia is defined as a visual quantitative

defect of enamel and is histomorphologically
identified as an external defect involving the surface
of the enamel associated with reduced thickness of
enamel.[1] Turner’s hypoplasia is a frequent pattern of
enamel defects seen in permanent teeth primarily due
to a periapical inflammatory disease of the overlying
deciduous tooth. The altered tooth is known as a
Turner’s tooth.[2] The degree of hypoplasia may vary
from a mild brownish discoloration of the crown in
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DOI:
10.4103/2229-5194.173232
maxillary and mandibular premolars.[3] If Turner’s
hypoplasia is found on a canine or a premolar, the
most likely cause is an infection that was present
when the primary tooth was still in the mouth. Most
likely, the primary tooth was heavily decayed, and an
area of inflamed tissues around the root of the tooth
affected the development of the permanent tooth.
The appearance of the abnormality depends on the
severity and longevity of the infection. If Turner’s
hypoplasia is found in the anterior area of the mouth,
the most likely cause is a traumatic injury to a primary
tooth. The traumatized tooth, which is usually a
maxillary central incisor, is pushed into the developing
tooth underneath it and consequently affects the
formation of enamel. Because of the location of the
permanent tooth’s developing tooth bud in relation
to the primary tooth, the most likely affected area
on the permanent tooth is the facial surface.[4] The

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Lavania and Lavania: Turners hypoplasia and its implications
Turner’s tooth can also be dilacerated along the crown or
the root of the tooth.[2] Dilaceration (Latin: dilacero = tear
up) refers to an angulation or a sharp bend or curve in the
root or crown of a formed tooth. Crown dilaceration is the
displacement of a portion of the developing crown at an
angle to the longitudinal axis of the tooth. It constitutes 3%
of total injuries to developing teeth.[3] The characteristics of
clinical enamel hypoplasia include unfavorable esthetics,
higher dentin sensitivity, malocclusion, and dental caries
susceptibility. The treatment challenge in this type of
injury is to promote a complete oral rehabilitation in both
esthetics and function.[5]
CASE REPORT
A 23‑year‑old female patient reported to the Department
of Conservative Dentistry and Endodontics, Goa Dental
College and Hospital with a chief complaint of the
discolored left upper front tooth from the time it erupted
in the oral cavity. On clinical examination, the maxillary
left central incisor showed brown discoloration [Figure 1]
with the irregular facial surface. There was a history of
trauma when the patient was 5 years old. There was
no history of treatment carried out. Medical history was
noncontributory. Also, the maxillary right central incisor
showed mild focal discoloration on the disto‑cervical
aspect of the facial surface.
On clinical examination, the tooth was noncarious and
nontender on percussion. Heat and cold tests were
performed to determine the vitality. The response was
negative. Intraoral periapical radiograph showed a
periapical radiolucency measuring approximately 0.5 cm
in diameter with respect to the tooth 21 [Figure 2]. A test
cavity was prepared in 21 and the tooth had no response,
indicating nonvitality. It was decided to perform the
endodontic therapy in the teeth 21. Thus, access opening
was accomplished. Working length was determined and
Figure 1: Preoperative photograph (lateral view)
76
biomechanical preparation was carried out with Hand
ProTaper files (Dentsply Maillefer, Ballaigues, Switzerland)
with the use of 3% sodium hypochlorite (Vensons India,
Bengaluru, India) as an irrigant. Calcium hydroxide
powder (Deepti Dental Products, Ratnagiri, India)
mixed with distilled water was placed as an intracanal
medicament for 2 weeks.
After 2 weeks, the canal was obturated up to apex with
Gutta‑percha points and AH Plus sealer (Dentsply Maillefer,
Ballaigues, Switzerland) [Figure 3].
After 3 months, periapical healing was observed and
the patient was then referred to an orthodontist who
decided to fabricate a Hawleys appliance for correction of
labial proclination. This treatment continued for a period
of 1 year, with activation of the appliance at monthly
visits [Figure 4].
After 1 year, the proclination was not completely
corrected, so it was decided to place a post in the tooth
and fabricate a ceramic facing crown to enhance the
esthetics. Post space preparation was carried out with
use of drills (Glassix, Nordin, Swiss dental products
of distinction) in the teeth 21 and Light Transmitting
Composite Post (Glassix, Nordin, Swiss Dental Products
of Distinction) was tried in the tooth. The post space
was etched (SS White Dental Pvt. Ltd., India), and the
bonding agent (3M ESPE Adper Single Bond 2, St. Paul,
USA) was applied and cured. Dual cure cement (Variolink
Low Viscosity, Ivoclar Vivadent, Liechtenstein) was used
and the post was cemented and cured again [Figure 5].
A restoration was done in composite for teeth 11 and
21 (shade A 3, Ivoclar Vivadent, Liechtenstein). Crown
preparation was done for 21, and metal ceramic crown
was fabricated and luted using Glass Ionomer Luting
Cement (GC Gold Label, GC Corporation Tokyo, Japan)
[Figures 5 and 6].
Figure 2: Preoperative intraoral periapical radiograph
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Lavania and Lavania: Turners hypoplasia and its implications
Figure 3: Postobturation radiograph
Figure 5: Postplacement
DISCUSSION
In the present case, the patient has a history of trauma at
5 years of age which is possibly responsible for damage to
the permanent tooth bud of the maxillary central incisors.
However, one tooth (21) was more affected than the other
tooth (11). Defective enamel and open dentinal tubules
probably acted as a nidus for bacterial entry into the pulp
space, thereby leading to pulpal necrosis, which could
possibly explain the reason for 21 being nonvital.
Pulpal reaction to dental trauma varies. The most common
complications are calcification and obliteration of the
pulp.[6] Calcification can vary from a small denticle to the
total obstruction of the pulpal canal.[7] The assessment of
trauma in primary dentition seems to be very important
because of sequelae in the permanent dentition. do
Espírito Santo Jácomo and Campos reported from their
longitudinal study of 8 years that discolorations of
enamel and/or enamel hypoplasia (46.08%) were the
most prevalent sequelae on permanent dentition due
to traumatic injury.[8] Traumatic injuries to the primary
Journal of Interdisciplinary Dentistry / May-Aug 2015 / Vol-5 / Issue-2
Figure 4: Hawleys appliance in place
Figure 6: Postoperative smile
dentition are very common, affecting from 4% to 30%
of all children.[9] With regard to the malformation of the
permanent tooth germ reported in this article, prior
studies[6,10‑15] support the finding that intrusion injuries are
the most common cause of developmental disturbances.
Fiber posts are passively retained inside the root canals,
and resin‑based luting agents are the materials indicated
for their retention. A wide variety and number of
prefabricated posts – made of stainless steel; zirconia; or
carbon, glass, or quartz fiber – are available in dentistry,
in different geometries and sizes. Clinically, the necessity
of placing a post arises when too little tooth structure is
present to sustain a coronal restoration. One of the critical
factors that can influence the survival of the restoration
is the retention capacity of the post. The post must be
cemented to the root canal walls in such a way that it
cannot be dislodged by external forces.[16] The posts should
transmit light to permit curing of the cement throughout
the apical region of the tooth. The use of dual‑cured or
self‑curing resin‑based cement has been recommended to
bond fiber‑reinforced, resin‑based composite posts to root
canal walls. The long‑term performance of restorations
in endodontically treated teeth with intracoronal posts
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Lavania and Lavania: Turners hypoplasia and its implications
depends on the retention of the post.[17] Translucent and
white fiber posts have increased in popularity in the last
few years, mainly due to the fact that they can be used
in high‑demand cosmetic procedures, such as with
all‑ceramic restorations. Translucent posts are not visible
through these types of restorations, thus yielding better
esthetic results than metal and carbon fiber posts. Ceramic
posts also offer good esthetics and are stronger and stiffer
than fiber posts, but they are more difficult to bond to
root canal walls. It is critical that the clinician considers
the mechanical properties of fiber‑reinforced composite
posts when designing or using a post restoration in an
endodontically treated tooth. For example, the quality
of the support of the coronal restoration can be reflected
by the stiffness of the post, being related to the loss of
retention of a crown. Posts with low strength and elastic
limits have an increased risk of failure due to distortion or
fracture. However, posts with elastic modulus similar to
that of dentin induce less stress in the root.[17]
CONCLUSIONS
The case we report here stresses the importance of
traumatic injuries to primary dentition because of their
effects on the permanent tooth germ. Injured teeth
should be followed up periodically for possible periapical
infections and pulp necrosis.[18] In addition, special care
may be necessary in the restoration of injured teeth
because their reaction patterns may differ from those of
nontraumatized teeth. Injury to the deciduous predecessor
might generate root or crown dilacerations to the
permanent dentition. The presence of severe dilacerations
increases the risk of an accident during the endodontic
procedure. Meticulous preoperatory examination and
a multidisciplinary approach to treatment planning is
strongly advocated.[19]
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How to cite this article: Lavania G, Lavania A. Endodontic and orthodontic
interdisciplinary management of a patient with Turner's hypoplasia.
J Interdiscip Dentistry 2015;5:75-8.
Source of Support: Nil, Conflict of Interest: None declared.
Journal of Interdisciplinary Dentistry / May-Aug 2015 / Vol-5 / Issue-2