The Tooth Had Not Fallen Out. It Had Been Driven Upwards.

Quick answer: A tooth that looks shorter than its neighbour after an injury has usually been pushed up into the bone, not knocked out. It is easy to mistake for a missing tooth. Intrusion is one of the more serious dental injuries and needs assessing urgently, because the treatment depends on the age of the patient and how far it has moved.

The call

A father in RBS Alef phoned in something close to panic. His nine-year-old, Ari, had come off an electric scooter on the hill, and one of his front teeth was "gone" — but there was no tooth on the pavement and no gap.

That description almost always means one thing.

What we found

The upper right central incisor was still present but sitting about 4mm higher than its neighbour, with only two-thirds of the crown visible. It was completely immobile — locked solid, which is characteristic. The gum around it was bruised and bleeding at the margin.

Percussion produced a high, metallic note rather than the dull note of a normal tooth. That sound is a genuine diagnostic sign: it means the root is jammed directly against bone with no ligament space between.

The x-ray confirmed intrusion of about 4mm, with loss of the ligament space at the root tip and no root fracture. The root apex was still open — not yet fully formed — which turned out to be the most important finding of the examination.

Intrusion is serious because everything is damaged at once: the ligament is crushed, the blood supply at the root tip is torn, and the bone around it is compressed. The risks afterwards are pulp necrosis, root resorption and ankylosis, where the tooth fuses to bone and stops moving with the growing jaw.

Treatment depends on three things:

How far it has moved. Under 3mm in a young patient, often left to re-erupt on its own. 3 to 7mm generally needs repositioning. Over 7mm needs surgical repositioning.

Whether the root is open or closed. Open apex teeth have a real chance of re-erupting spontaneously and of the pulp surviving. Closed apex teeth rarely do either.

The patient's age. Growth helps.

What we did

Given 4mm of intrusion with an open apex in a nine-year-old, we allowed three weeks to see whether it would re-erupt spontaneously. It moved about 1mm and then stopped.

At three weeks we referred him for orthodontic extrusion: a bracket bonded to the tooth and a light elastic force applied over six weeks to draw it gently back down. Slow traction is far kinder to the ligament and the bone than a surgical push.

We monitored the pulp throughout. At eight weeks the tooth stopped responding to testing and began to darken — the nerve had died, as it does in the majority of intrusions of this severity even with an open apex. Root canal treatment followed, using a calcium-silicate apical plug because the root end was still open and could not be sealed conventionally.

The outcome

The tooth is back at the correct height and matches the neighbouring tooth. Root treated, restored, and stable at three years, with no resorption visible so far.

He is being followed annually. Late resorption and ankylosis can appear years afterwards, and if the tooth ever ankyloses while his jaw is still growing, it will need managing then.

What to do if this happens to you

1. A tooth that looks shorter is not a missing tooth. Do not go hunting on the pavement; go to a dentist.
2. Do not try to pull it down or wiggle it. It is locked in bone and you will do further damage.
3. Be seen the same day. Treatment decisions are time-sensitive.
4. Mention the child's age and whether the tooth is fully formed. It genuinely changes the plan.
5. Expect a long follow-up. These teeth are monitored for years, not months.
6. Check for head injury. A blow hard enough to intrude a tooth is a significant impact.

Tooth pushed up into the gum after a fall? Call Ramat Beit Shemesh Urgent Dental Care the same day: 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh.

Based on real cases treated at the clinic. Names have been changed.