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Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 136-139

Delayed replantation of avulsed tooth with 4½ days extraoral time with 18 months follow up

Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication13-Jun-2017

Correspondence Address:
Ramasubbareddy Challa
Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore - 524 003, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-8632.208006

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Avulsion or exarticulation is one of the most severe injuries of the tooth, frequently encountered in young children and the maxillary anterior teeth. Immediate transplantation of the avulsed tooth is the suggested treatment that results in a favorable prognosis, although this may not be possible every time. Here, we present a case report of an 8-year-old girl who sustained an avulsion injury of the maxillary left central incisor with 4½ days extraoral time. Treatment guidelines for avulsed immature permanent teeth with prolonged extraoral dry time were followed. Portland cement was used for obturation of the root canal. The clinical and radiographic findings after 18 months revealed minimal inflammatory root resorption and ankylosis of the replanted tooth, whereas clinically, the tooth was asymptomatic and maintained the aesthetics of the child, suggesting the importance of replantation, although there was prolonged extraoral dry time.

Keywords: Avulsion, delayed replantation, Portland cement

How to cite this article:
Kolli NK, Challa R, Karthik A, Nuvvula S. Delayed replantation of avulsed tooth with 4½ days extraoral time with 18 months follow up. J NTR Univ Health Sci 2017;6:136-9

How to cite this URL:
Kolli NK, Challa R, Karthik A, Nuvvula S. Delayed replantation of avulsed tooth with 4½ days extraoral time with 18 months follow up. J NTR Univ Health Sci [serial online] 2017 [cited 2021 May 11];6:136-9. Available from: https://www.jdrntruhs.org/text.asp?2017/6/2/136/208006

  Introduction Top

Tooth avulsion is defined as the complete displacement of the tooth out of its alveolar socket. It is a serious form of tooth injury resulting in damage to the periodontal ligament (PDL), cementum, alveolar bone, as well as the gingival and pulpal tissues. Its prevalence accounts for 1–16% of traumatic injuries in permanent dentition.[1],[2] Maxillary central incisors are the most common teeth to be involved with a male predilection (male:female = 3:1).[3] Avulsion is most commonly observed in young age due to the resilient nature of the bone, periodontium, and incompletely formed roots,[1],[2] with loss of function in addition to a negative impact on the quality of life, leading to psychological and social discomfort.

Children aged 7–14 years are the most commonly affected, which makes it difficult in maintaining the tooth and surrounding bone until completion of facial growth. Hence, success does not necessarily mean that the tooth is healthy and functioning for the entire life of the patient and maintaining the tooth; circumventing bone for a few additional years can be considered as a successful treatment in children and adolescents.[4]

The recommended treatment for avulsed tooth is immediate replantation; however, it is not always possible due to the patient's concomitant injuries at the time of the accident and lack of acquaintance in the management of such injuries at the site of the accident.[5] The present case report describes a rare case of a replanted young permanent maxillary left central incisor with an extraoral period of 4½ days and its 18 months follow up observations.

  Case Report Top

An 8-year-old female child reported to the department of paediatric dentistry with a history of trauma sustained more than 4 days ago and a chief complaint of broken upper front tooth. The trauma occurred due to a fall from a parked heavy motor vehicle while playing, and there was no history of loss of consciousness or vomiting. After 22 hours of extraoral dry time, the tooth was taken to a local dentist wherein the tooth was placed in saline. A local dentist referred the child to our department for subsequent treatment, however, they reported late due to negligence (total extraoral time was approximately 114 hours with approximately 92 hours of wet storage time).

The child had mixed dentition and carious lesions on all primary second molars due to poor oral hygiene. Ellis class II injury was noted on 11 and 22, whereas class V injury on 21. Examination of the avulsed tooth showed that the crown had enamel and dentine fracture, root had an open apex, and the root surface was covered with remnants of periodontal ligament. There was no evidence of alveolar bone fracture both clinically [Figure 1]e and in the periapical radiograph [Figure 1]a. After informing the parents about the possible risks and taking consent, the socket of the tooth was prepared by using curettes, followed by gentle rinsing with saline solution under local anesthesia. Necrotic and dried remnants of the periodontal ligament tissue were carefully removed from the root surface with pumice prophylaxis. Tooth was soaked in 2% sodium fluoride (2% NaF) for approximately 20 minutes. Extraoral endodontic treatment was carried out followed by root canal filling with Portland cement and restoration of the access cavity with Glass ionomer cement (Ketac Molar, 3M/ESPE Dental Products, St. Paul, MN, USA). The tooth was replanted gently with slight digital pressure, and the position of the replanted tooth was verified both clinically and radiographically before stabilization using a flexible splint by employing an acid-etch composite resin technique [Figure 1]b and [Figure 1]f. Postoperative oral hygiene instructions, a soft diet, and the need to use a chlorhexidine mouthwash were advised during the stabilization period. Antibiotic therapy with amoxicillin at a thrice daily per dose of 250 mg was prescribed for 1 week. The patient was referred to the paediatrics department for tetanus booster. The parents were informed about the importance of regular recalls for clinical and radiographic follow-up. The child was reviewed after 2 weeks, and there were no observable pathological changes, both clinically and radiographically. Splinting was removed and the fractured crowns were restored permanently with resin composite. Periodic evaluation at 12 months and 18 months showed that replanted tooth remained in a stable functional position [Figure 1]g but with initial replacement resorption and ankylosis [Figure 1]c and [Figure 1]d. The child will be under continuous supervision and appropriate treatment will be carried out if needed.
Figure 1: (a) Preoperative radiograph. (b) Radiograph after reimplantation and splinting. (c) Radiograph after 1-year follow up. (d) Radiograph after 18-month follow up. (e) Preoperative clinical picture. (f) Clinical picture after reimplantation and splinting. (g) Clinical picture after 18-month follow up

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  Discussion Top

In the present case, saline was used as interim transport medium for 92 hours. Saline is a reasonable storage medium due to its osmolality; however, it can preserve periodontal ligament cells viability up to 4 hours.[6] Nevertheless, in the present case, the tooth was not stored in any medium up to 22 hours, and hence it was thought that the PDL cells were already dead and the avulsed tooth was considered category 4.[7] The root surface of the tooth was cleaned with soft pumice prophylaxis to remove the remaining dead PDL cells to prevent infection-related resorption, which in turn slows down the osseous replacement of root surface.[7] Then, the tooth was immersed in NaF solution for 20 min till the armamentarium and the tooth socket were prepared for the procedure to minimize the loss of valuable time. The authors chose to soak the avulsed tooth in 2% NaF gel for 20 minutes to delay the ankylosis progression.[8] NaF has been suggested for pretreatment of root surface since 1968 because of its beneficial effect by delaying the progression of root surface resorption after replantation.[9] Stannous fluoride has also been suggested as an alternative for the treatment of root surfaces before replantation; however, its use has been associated with long-standing inflammatory reaction in PDL.[10] Therefore, NaF has been preferred over stannous fluoride for root pretreatment before replantation.[9]

Tooth was placed in the socket and flexible type of splinting was done for 2 weeks using acid etch composite resin and multiflex wire from canine to canine. Although various types of semirigid splints (or flexible splint) have been recommended, this splint was used because of immediate availability in the department. This splint allows maintenance of oral hygiene as well as easily tolerated by the child.[2] Because the child was younger than 12 years, amoxicillin was used as the drug of choice to avoid the chance of discoloration and it has antibacterial effect similar to tetracycline.[11]

Where external root resorption is an expected sequel, mineral trioxide aggregate (MTA) can be considered as a viable option for root canal filling.[12] Owing to economic concerns of the parents, Portland cement was preferred instead of MTA. In the present case, inflammatory root resorption and ankyloses (replacement resorption) are the associated complications due to which the tooth is expected to be lost eventually by gradual resorption of the root surface followed by replacement with bone. Radiographic characteristics of ankylosis include obliterated PDL space and continuous replacement of root substance with the bone until little or no tooth substance remains. In contrast, radiolucent bowl-shaped cavitations along the root surface may often begin on the cervical third, which are radiographic characteristic features of inflammatory root resorption. In the present case, lack of physiologic mobility of the tooth and metallic sound on percussion gives us an indication of ankylosis. In a growing child, ankylosed tooth is often considered as a desirable outcome as a transitional condition after delayed replantation.[4] Preserving the root conserves the alveolar bone, which is advantageous for implant placement, once the child growth is complete. Hence, after the completion of growth, permanent restoration such as implants or fixed partial dentures can be considered.

Another factor which should be highlighted in the present case is to understand the basic reason for delay in seeking treatment. If the tooth could have been reimplanted by the parents/child and immediate treatment provided by local practitioner or reported to the specialist without delay, the prognosis could have been much better in terms of resorptive process and its signs could have been delayed or in best circumstances (as in the case of immediate replantation), completely prevented. In the present case, initial resorptive signs appeared radiographically after 12 months of replantation, though the extraoral time was approximately 120 hours; hence, the present case can be considered as a clinical success because tooth and surrounding bone can be preserved for a few additional years and further permanent restoration can be carried out without considerable complications.

  Conclusion Top

Although satisfactory results were observed after following up for 18 months, further clinical and radiographic observations are required. Objectives of replantation can be successfully accomplished by proper pretreatment of the avulsed tooth even if replantation is done in unfavorable condition. In children for whom growth has not ceased, maintaining the circumventing bone for additional years until the child is suitable for permanent restoration can be considered as a viable therapeutic option. Emphasis should be made on educating all dentists, school teachers, road traffic police, and primary healthcare personnel including nurses regarding the importance of preserving an avulsed tooth, methods of preservation, and rationale for replantation, and update them with the recent guidelines on management of such teeth.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Andreasen JO, Andreasen FM, Classification, etiology and epidemiology. In: Andreasen JO, editor. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd ed. St. Louis: Mosby; 1994. p. 151-79.  Back to cited text no. 1
Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dental Traumatol 2012;28:88-96.  Back to cited text no. 2
Bastone EB, Freer TJ, McNamara TR. Epidemiology of dental trauma: A review of the literature. Aust Dent J 2000;45:2-9.  Back to cited text no. 3
Trope M. Avulsion of permanent teeth: Theory to practice. Dent Traumatol 2011;27:281-94.  Back to cited text no. 4
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. Factors related to pulpal healing. Endod Dent Traumatol 1995;11:59-68.  Back to cited text no. 5
Moreira-Neto JJS, Gondim JO, Raddi MSG, Pansani CA. Viability of human fibroblasts in coconut water as storage medium. Intern Endod J 2009;42:827-30.  Back to cited text no. 6
McIntyre JD, Lee JY, Trope M, Vann Jr. WF. Permanent tooth replantation following avulsion: Using a decision tree to achieve the best outcome. Pediatr Dent 2009;31:137-44.  Back to cited text no. 7
Selvig KA, Zander HA. Chemical analysis and microradiography of cementum and dentin from periodontally diseased human teeth. J Periodontol 1962;33:303-10.  Back to cited text no. 8
Coccia CT. A clinical investigation of root resorption rate in replanted young permanent incisors: A five year study. J Endod 1980;6:413-20.  Back to cited text no. 9
Bjorvatn K, Selvig KA, Klinge K. Effect of tetracycline and SnF2 on root resorption in replanted incisors in dogs, Scand. J Dent Res 1989;97:477-82.  Back to cited text no. 10
Hammarstrom L, Blomlof L, Feiglin B, Andersson L, Lindskog S. Replantation of teeth and antibiotic treatment. Endod Dent Traumatol 1986;2:51-7.  Back to cited text no. 11
Marao HF, Panzarini SR, Aranega AM, Sonoda CK, Poi WR, Esteves JC, et al. Periapical tissue reactions to calcium hydroxide and MTA after external root resorption as a sequela of delayed tooth replantation. Dent Traumatol 2012;28:306-13.  Back to cited text no. 12


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