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Reimplantation Of Avulsed Teeth After Dry Storage For

One WeekSurekha Puri,

1SupratimTripathi

2Mihir Pandya,

3Pooja Trivedi

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Introduction

Avulsion is defined as a complete separation of a tooth from its alveolusfollowing a traumatic injury which results in extensive damage to the pulp andperiodontal tissues4. Reimplantation refers to the insertion and temporary fixation ofcompletely or partially avulsed teeth that have resulted from traumatic injury.

Studies have shown that teeth that are protected in a physiologically idealmedia can be replanted twenty-four hours after the accident with good prognosis. Thesuccess of delayed reimplantation depends on the vitality of the cells remaining on theroot surface

2,,the length of extra oral dry time

1and the stage of root development.

Avulsion of teeth results from traumatic injuries in the oro-facial region. WorldHealth Organizations classification system later modified by Andreasen, avulsion isclassified as an

- injury of periodontal tissues,- extrusive,- lateral, or- intrusive luxation.

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As a treatment option, reimplantation restores occlusal function and estheticsshortly after injury. In reimplantation complete reestablishment of vitality ofperiodontal fibers is the prime objective. The percentage of success of tooth

reimplantation has been observed to be low, ranging from 4 to 50%.1

Thereattachment of periodontal fibers and the formation of Sharpey fibrils occur about 2weeks after reimplantation .5

Extra-alveolar dry time and the storage media used to transport the tooth arecritical factors for successful and long-term outcomes . Treatment is often complex,time-consuming, expensive and requires multidisciplinary approaches such asendodontic and periodontal treatment, surgery, orthodontic movements and estheticcoronal restoration. Reimplantation-associated root resorption can often result incomplications such as infra-occlusion leading to poor esthetics, tilting of adjacentteeth, loss of function and eventually loss of the affected teeth . The benefit of toothreimplantation in such cases is mainly the time gained to establish an optimalpermanent treatment plan and preservation of the width of the alveolar bone.

IJCDSAUGUST, 20112(3) 2011 Int. Journal of Clinical Dental Science

ABOUT THE AUTHORS

1. Dr. Surekha Puri,

Associate ProfessorDepartment Of ConservativeDentistry & EndodonticsPacific Dental College

Udaipur, India

2.Dr. SupratimTripathi

Post Graduate StudentDepartment Of ConservativeDentistry & EndodonticsPacific Dental CollegeUdaipur, India

2.Dr. Mihir Pandya

Post Graduate StudentDepartment Of ConservativeDentistry & Endodontics

Pacific Dental CollegeUdaipur, India

3. Dr. Pooja Trivedi

Post Graduate StudentDepartment Of ConservativeDentistry & EndodonticsPacific Dental CollegeUdaipur, India

Corresponding Author:

Dr. Mihir Pandya

Post Graduate Student

Department Of Conservative

Dentistry & Endodontics

Pacific Dental College

Udaipur, India

Email:

dr.mihirpandya@yahoo.com

A stract

Management of tooth avulsion in the permanent dentition often presents a challenge. Avulsion

is serious injury cause damage to dental and supportive tissues, ranges from 1-16 % among

dental injuries and it mostly occurs in maxillary incisors. Definitive treatment planning and

consultation with specialists is seldom possible at the time of emergency treatment.

Replantation of the avulsed tooth can restore esthetic appearance and occlusal function shortly

after the injury. This article describes the management of a female patient with an avulsed

maxillary permanent incisor that had been air-dried for about 7 days.

KEYWORDS: tooth avulsion, Replantation, permanent dentition

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CASE REPO

mailto:dr.mihirpandya@yahoo.commailto:dr.mihirpandya@yahoo.commailto:dr.mihirpandya@yahoo.com

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Case report

A 18 years old patient reported to the department ofconservative dentistry and endodontics Pacific DentalCollege ,Udaipur ,Rajasthan with her knocked out toothrolled in a paper.The patient had the injury due to fallingin a road traffic accident from a bicycle one week back.On clinical examination it was revealed that there was noswelling present with upper front region of the face.On

intraoral examination it was found that the socket of theknocked out tooth was dry with no signs of bleeding.

Fig 1.Pre-operative photograph

On examination, the patient did not show anysigns or symptoms of neurological or extraoral injury,and she presented with a class III skeletalrelationship.She had sufficient over jet and over bite soreimplantation can be planned ,as the was nointerference from the opposite arch thus no trauma

from occlusion .Oral hygiene was fair, and no carious lesionswere detected clinically. on vitality test with the adjacentteeth it was found that left side lateral incisor was nonvital. Radiograph was obtained, and no other hard-tissueinjury was detected in that region.Examination of the avulsed tooth revealed that the

crown was intact and that the root had a nearly closedapex, but the root surface was covered with driedremnants of periodontal tissue.It was estimated that the avulsed tooth had been keptdry for about almost 7 days. The root of the avulsedtooth was planned to remove the necrotic periodontal

tissue and was then filled with gutta-percha points andsealer extra orally.

Surface treatment of the root was done withcitric acid and the consecutively stannous flourideapplication was done on the root surface for 10 minutesand then rinsed with saline.Tooth was then placedsubmerged in HBSS solution[Hanks balanced saltsolution] till the granulation tissue was removed fromthe socket.[fig 2]

The available treatment options were explained to theparent, and it was decided to reimplant the avulsed

incisor as an intermediate treatment. Local anestheticwas administered and the blood clot removed from thesocket. A surgical curette was used to remove thegranulation tissue and induce fresh bleeding.The socketwas regularly irrigated with chlorhexidine gluconate andsaline .The tooth was then finally placed into the socket and

held under pressure in order to achieve the propeplacement of the tooth .The labial and the palatacortical plates were pressed in order to provide properapproximation .

Then while keeping the tooth under pressure the teethwere etched in order to place the splint for imbolizingthe tooth. Etching was done with 37%phosphoric acidAll the teeth were then rinsed with the avulsed tooth stilunder pressure. Bonding agent(prime bond NT) wasapplied on all the teeth, etched and cured .Anorthodontic wire of 19 guaze was used to splint the teethalong with composites for 6 weeks[fig2 &3].

Fig2&3. An orthodontic wire and composite splint in place

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physiologic saline or water . Water is the least desirablestorage medium because the hypotonic environmentcauses rapid cell lysis and increased inflammation onreplantation.

6 Andreasen reported that root resorption

increased after 18 minutes of dry storage of teeth, butboth Cvek et al and Matsson et al. Showed that teeththat have been dry-stored for between 15 and 60minutes will demonstrate less root resorption if they aresoaked in HBSS for 30 minutes before replantation..

Therefore, teeth that have been extraoral for 15 minutesor more should not be reimplanted immediately butshould be soaked in a ph-balanced cell-reconstitutingmedia for 30 minutes before replantation.

7 Once the

teeth have been placed in HBSS, time no longer is ascritical.

7Even if the avulsed teeth have been stored in a

physiologic medium, such as normal saline solution ormilk, from the moment of the avulsion accident, theteeth should still be soaked in HBSS for 30 minutesbefore reimplantation, because neither saline solutionnor milk can replenish depleted PDL cell metabolites.

7 It

is probable that the root surface will contain some viableperiodontal cells, and some that will act as stimulators of

infammation.

Exra-oral dry time more than 60 min Closed Apex

Remove the periodontal ligament by placing inacid for 5 min, soak in fluoride or cover the root withendogain. When the root has been dry for 60min ormore, the periodontal ligament cells are not expected tosurvive.

(1,2)In these cases, the root should be prepared to

be as resistant to resorption as possible (attempting toslow the osseous replacement process). These teethshould be soaked in acid for 5min to remove allremaining periodontal ligament and thus remove thetissue that will initiate the inflammatory response onreimplantation.

The tooth should then be soaked in 2%Stannous fluoride for 5min and reimplanted .The socketshould be left undisturbed before reimplantation.Emphasis is placed on the removal of obstacles withinthe socket to facilitate the replacement of the tooth intothe socket . It should be lightly aspirated if a blood clot ispresent. If the alveolar bone has collapsed, a factorwhich may prevent reimplantation or cause it to betraumatic, a blunt instrument should be insertedcarefully into the socket in an attempt to reposition the

wall.

SplintingA splinting technique that allows physiologic

movement of the tooth during healing and that is inplace for a minimal time period results in a decreasedincidence of ankylosis .

In this case splinting was done with compositeand orthodontic wire. The advantage of this technique isthat it is much less stressful to the injured area becausethe forces needed to apply the material are far lessintense than those needed to apply for arch bars. An

acid-etched resin splint with orthodontic wire is easy tofabricate but does not allow the teeth much mobility .

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Follow-Up Care

Follow-up evaluations should take place at3months, 6 months and yearly for at least 5 years. Ifosseous replacement is identified, timely revision of thelong-term treatment plan is indicated. In the case of

inflammatory root resorption, a new attempt atdisinfection of the root canal space by standardretreatment can reverse the process.

Conclusion

Reimplanting avulsed teeth should beconsidered as a temporary solution in children andadolescents . In these patients, the greatest benefit ofsuccessful reimplanation of an avulsed tooth ispreservation of alveolar bone. Even if the reimplantedtooth must be extracted later, the improved alveolar

development will provide better options for restorationof the site later. We could successfully achieve objectiveslike acceptable esthetic appearance and occlusafunction ,prevention of root resorption and favorablehealing for better permanent treatment considerations inlater life. Patient was asymptomatic and fully satisfiedwith the treatment with a follow up of 6 months and 12months.This procedure will give invaluable and timelycontribution in their normal and physiological growth.

References

1 Reimplantation: Clinical Implications And Outcome ofDry Storage of Avulsed Teeth J Clin Exp Dent2010;2(1):e37-41.

2. Treatment of knocked-out (avulsed) teeth. Wikipediathe free encyclopedia

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5. Histological evaluation of a replanted toothRetained for 49 yearsdental Traumatology 2006; doi10.1111/j.1600-9657.2006.00337.x

6. Clinical management of the Avulsed tooth: presenstrategiesand future directions Dental Traumatology2002: 18: 111

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7. Avulsed teeth: improving the prognosis, Part 2: aguide to Selecting the best storage medium.(Endo faqs:DPR Exclusive: Avulsed teeth) Article from: DentalProducts Report | June 1, 2007 | Krasner, Paul R.

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10. Replantation and transplantation following Avulsionof two maxillary incisors Dental Traumatology 2007; doi10.1111/j.1600-9657.2005.00367.x

11. Medicolegal Aspects of Replanting Permanent TeethJ Can Dent Assoc 2005; 71(4):2458

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