REIMPLANTATION OF AVULSED TOOTH- A CASE REPORT

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1 Case Report REIMPLANTATION OF AVULSED TOOTH- A CASE REPORT Grover PS 1, Kaur S 2 1 Senior Consultant, 2 Junior Consultant, Dr. Grover s Dental and Implant Center, Ludhiana ABSTRACT This paper describes a case of complete management of a traumatized maxillary central incisor which was avulsed after a road traffic accident. The case was followed up by repeated calcium hydroxide dressings to ensure complete recovery of the lamina dura before proceeding with the final obturation. This case gives us an insight as to the importance of conservative management with use of aggressive measures at the right time for the right case. Keywords: Avulsion; Reimplantation; Calcium hydroxide Corrseponding Author: Dr. Parminder Singh Grover,Senior Consultant, Dr. Grover s Dental and Implant Center, Ludhiana. How to cite:grover PS and Kaur S. Reimplantation of Avulsed Tooth A Case Report. IDA Lud J le Dent 2017;1(2): INTRODUCTION Dental emergencies, especially traumatic injuries to the teeth are one of the most frequently encountered by a dentist. Through this article, a case report is being discussed where a patient who met with a traumatic injury, resulted in an avulsed Tooth. The most common avulsed teeth are the maxillary central incisors which represent 1-16% of traumatic injuries to permanent dentition 1, mainly because of some predisposing factors like protrusion, etc. A tooth if completely avulsed, requires immediate attention because if the PDL breaks down, it can lead to pulpal necrosis if not encountered in time. The best outcome of an avulsed tooth is that if it is treated within time, we can expect re-organisation of the new attachment apparatus. This happens because of an underlying inflammatory response and healing being directly related to time and extra oral dry condition 2. The American Association of endodontics (AAE) aims the treatment plan to minimize damage to root cementum and PDL (Periodontal Ligament). Based on all factor considerations, the treatment plan is divided into 2 phases: Emergency Treatment and Definitive Treatment. Emergency treatment involves replacement of tooth into socket, if possible immediately within 15 IDA Ludhiana s Journal ledentistry Vol.1 issue

2 min. 3 If not, it s the duty of the dentist to guide the patient regarding storage media and to bring the tooth in Hanks Balanced Salt Solution 4, which is considered the gold standard, followed by cold low fat Milk 5 and finally saline. When in the clinic, clean the socket with saline/chlorhexidine and position the tooth back into the socket, suture and verify position radiographically. The definitive treatment phase is again divided into 2 phases, depending on extraoral dry time & conditions. If the extra oral dry time is less than 60 minutes and the tooth has been brought in a biological medium like HBSS, a conservative treatment protocol is followed which involves cleaning the socket with saline and then reimplanting the tooth with digital pressure 6. If the apex is closed, then endodontic treatment is performed within 7-14 days. In case if it is an open apex, soak the tooth in doxycycline 0.005% for 5 min and then reimplant. In such cases, endodontic treatment should be deffered and all efforts made to maintain vitality. In case the extra oral time is more than 60 mins, the prime concern is to slow down the necrotising PDL and the process of root resorption for which IADT (International Association of Dental Trauma) 7 gives the concept of Root Pre-conditioning. It involves treatment of root surface with EDTA (24%), citric acid/sodium hypochlorite 8 to remove necrotic tissue followed by irrigation with saline. Next, soak tooth in sodium fluoride 2.4% (5.5 ph) for 20 mins. After this, the procedure is similar i.e., the treatment of dental socket with saline irrigation and flap elevation only if bone interferes with reimplantation of tooth. International Association of Dental Traumatology (IADA) guideline for management of avulsed mature permanent teeth replanted after 60 min in dry extra oral conditions also endorses use of Emdogain prior to replantation for reasons same as those listed above. 9 Suturing should be done for any lacerations. This is followed by tooth immobilization with the help of a semi rigid splint for 7-10 days 10 accompanied by maintenance of good oral hygiene. This all has to be supported by pharmacological intervention including antibiotic coverage for systemic action to prevent development of external root resoption 11. Penicillins are the most preferred group for this purpose. Endodontic Treatment to be carried out depends on the state of root development i.e. either the apex is Closed or Open. For a Closed Apex, in case the extra oral dry time is more than 15 mins, the tooth is stored in biological medium, a root canal is done within days with Ca(OH) 2 as intracanal medication (2 6 weeks). It has been shown that Ca(OH) 2 promotes disinfection of root canal and prevents inflammatory root resorption 12. For an Open Apex, the only way to conserve it is to replant the tooth immediately within less than 1 hour with biocompatible material like MTA(Mineral trioxide aggregate) CASE REPORT A 29 year old male presented with history of trauma (H/O Road Traffic Accident) 3 hours prior to reaching the dental clinic. As soon as the patient called, he was asked to store the tooth in a biological medium; the best available at that time being milk. When the patient reached the clinic (Fig 1), following the ideal protocol, the root surface was preconditioned with sodium hypochlorite to remove necrotic tissue (Fig 2). The dental socket was cleaned and irrigated well with saline (Fig 1), following which root canal was started extra-orally (for it was a closed apex). After cleaning the canal, the tooth (Initial BMP done) was repositioned into the socket with semi rigid splinting (Fig 3). IDA Ludhiana s Journal ledentistry Vol.1 issue

Seven days after initial immobilization (Fig 4), Ca(OH)2 dressing was placed into the canal to ensure temporary root canal filing material along with its anti bacterial properties.

All the above was however supported by pharmacological intervention of Antibiotic Coverage analgesics and soft diet.the patient is still on recall.

Reimplantation, After root conditioning and initiation of endodontic procedure. Fig 4: Semi-Rigid Splinting, Tooth immobilized.

For the above answers, the patient s history as well as the guidelines 4 mentioned for the treatment that are frequently updated by the International Association of Dental Traumatology must be

3 Seven days after initial immobilization (Fig 4), Ca(OH)2 dressing was placed into the canal to ensure temporary root canal filing material along with its anti bacterial properties. The dressing was changed every 3 months (for 6-12 months) till an intact lamina dura was seen radiographically and then the tooth was finally sealed with gutta percha. All the above was however supported by pharmacological intervention of Antibiotic Coverage analgesics and soft diet.the patient is still on recall. Fig 1: Pre Treatment-Bleeding socket which was irrigated with saline brought in biological medium, Fig 2: Pre Conditioning Tooth dipped in milk was conditioned using sodium hypochlorite, Fig 3: Reimplantation, After root conditioning and initiation of endodontic procedure. Fig 4: Semi-Rigid Splinting, Tooth immobilized. DISCUSSION Though avulsed teeth are quite frequently encountered by dentist, but still the question of concern remains as to how to treat, when to treat and where to start treatment? For the above answers, the patient s history as well as the guidelines 4 mentioned for the treatment that are frequently updated by the International Association of Dental Traumatology must be reviewed in order to obtain the best results based on evidence based dental management. The primary concern in such cases is to prevent the loss of attachment apparatus and ensure no further harm to PDL for which the tooth is always advisable to be brought in a biological medium like HBSS, Viaspan or cold low fat milk. This prevents or slows down the natural pace of necrotising PDL 13. Next in line, lies the question for immediately replacing the tooth back into socket in less than 15 mins as the inflammatory response time survives between the same. But after that, the best concept is of root planning 14 and the reason behind this aggressive protocol lies in the removal of debris and thus ensuring a body adapting inflammatory reaction leading to regaining of the attachment apparatus which also limits the replacement resorption 15. More or less calcium hydroxide dressings play a very vital role as it acts both as a medicament and a temporary seal during the healing phase 16 through which an intact lamina dura is regained. The above answers are all secondary to the fact that the most important area of concern in such cases has to be the extra oral dry conditions and inflammatory response of body which will ultimately determine the treatment outcome. REFERENCES 1. Fountain SB, Camp JH. Traumatic injuries. In:Cohen S, Burns AC, eds. Pathways of the Pulp.6 th ed.st Louis: Mosby; Andreasen JO. Periodontal healing after replantation of traumatically avulsed human teeth. Assessment by mobility testing and radiography. Acta Odontal Scand1975;335: Andreasen JO, Kristerson L. The effect of limited drying or removal of the periodontal ligament: Periodontal healing after replantation of mature permanent incisors in monkeys. Acta Odontal Scand 1981;39:1-13. IDA Ludhiana s Journal ledentistry Vol.1 issue

4 4. Flores MT, Andreasen JO, Bakland LK, et al. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol.2001;17: Andreasen JO. The effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys. Int J Oral Surg. 1981;10: Andreasen JO, Hjorrting-Hasen E. Replantation of teeth. Radiographic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontal Scand.1966;24: Hiltz J, Trope M. Vitality of human lip fibroblasts in milk, Hank s Balanced Salt Solution, and Viaspan storage media. Endod Dent Traumatol.1991;7: Trope M, Friedman S. Periodontal healing of replanted dog teeth stored in Viaspan, milk and Hank s Balanced Salt Solution. Endod Dent Traumatol.1992;8: Blomloff L. Milk and saliva as possible storage media for traumatically exarticulated teeth prior to replantation. Swed Dent J.1981;8: Selvig KA, Bjorvatn K, Bogle GC, Wikesjo UME. Effect of stannous fluoride and tetracycline on periodontal repair after delayed tooth replantation in dogs. Scand J Dent Res.1992;100: Yang ZP, Chan CC, Yang SF, Lee G. The inter-relationship between the root surface and alveolar bone of replanted avulsed tooth after etching. Zhonghua Yi Xue Za Zhi(Taipei).1989;44: Andreasen JO, Andreasen FM. Textbook and Color Atlas of Traumatic Injuries to the teeth. 3 rd ed. Copenhagen: Munksgaard;1994: Hammarstrom L, Blomloff L, Feiglin B, Andersson L, Lindskog S. Replantation of teeth and antibiotic treatment. Endod Dent Traumatol.1986;2: Hammorstrom L, Pierce A, Blomloff L, Feiglin B, Lindskog S. Tooth avulsion and replantation. Endod Dent Traumatol.1986;2: Bryson EC, Levin L, Banchs F, Abbot PV, Trope M. Effect of immediate intracanal placement of Ledermix Paste on healing of replanted dog teeth after extended dry times.dent Traumatol.2002;18: Wong KS, Sae-Lim V. The effect of intracanal Ledermix on root resorption of delayed replanted monkey teeth. Dent Traumatol.2002;18: Conflict of Interest :None Source of Support: Nil This work is licensed under a Creative Commons Attribution 4.0 International License IDA Ludhiana s Journal ledentistry Vol.1 issue

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Guidelines for the evaluation and management of traumatic dental injuries

Guidelines for the evaluation and management of traumatic dental injuries Dental Traumatology 2001; 17: 193 196 Copyright C Munksgaard 2001 Printed in Denmark. All rights reserved DENTAL TRAUMATOLOGY ISSN 1600-4469 Editor s note The International Association of Dental Traumatology