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Case Report

Reimplantation of an air dried avulsed permanent central incisor with 72 months follow-up Neeraj Kumar, Richa Kumari

Oral Health Sciences Centre, Pgimer Chandigarh

Received: 20 September 2019 / Accepted: 01 November 2019

Abstract Management of tooth avulsion in the permanent dentition often presents a challenge to the general dentist. Immediate or

delayed reimplantation can restore the occlusion stability and aesthetic appearance if implemented. This article highlights the management of a 9 year old child with an avulsed left maxillary permanent incisor that had been air dried for about 4 hours. The replanted central incisor restores the aesthetics and function. Although, the long-term prognosis

is not good because of inflammatory/ replacement root resorption in the avulsion cases where the dry time is more than 60 minutes however the tooth does not show any replacement root resorption even after 72 months of follow up.

Keywords: Reimplantation; root resorption; avulsion; permanent dentition

Introduction

Tooth avulsion is defined as total displacement of the tooth out of its alveolar socket. The prevalence of traumatic injuries in the permanent dentition was found between 0.5-16%.1 Tooth avulsion occurs most often between 7 to 9 years of age, as at the younger age resilient nature of alveolar bone provides minimal resistance to extrusive forces.1 The

maxillary permanent central incisors are the most commonly affected teeth because of increased overjet and proclination with greater incidence in boys. There are various treatment modalities in these cases which include reimplantation, prosthetic replacement, space closure or auto transplantation of the premolar together with orthodontic

treatment and full coverage crowns.2 As prosthetic and orthodontic treatment modalities are not possible at the time of emergency treatment so reimplantation of avulsed tooth is often recommended and is the treatment of choice. Reimplantation restores the patient’s esthetic and functional stablility for few years. The critical event in reimplantation

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Worldwide Medicine

Corresponding Author: Neeraj Kumar -Oral Health Sciences Centre, Pgimer Chandigarh Email: dr.neeraj001@gmail.com DOI: 10.5455/ww. 66225 This is an Open Access article under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/)

Kumar et al. WW Med 2019 Vol 1 issue: 8 284-287

procedure is the preservation of vitality of the periodontal ligament cells under aseptic conditions, as regeneration of the

periodontal ligament is vital to the survival of the tooth.3 There are chances of replacement root resorption or ankylosis if the extra oral dry time is more than 1 hour, however reimplantation as a treatment option should be done whether extraoral dry time has extended more than 60 minutes. This case report highlights the reimplantation of an avulsed permanent maxillary central incisor with extra-

alveolar dry time of more than 4 hours with no inflammatory/replacement resorption even after 72 months of follow up. Case Report A 9 year old male patient reported with missing upper front tooth due to fall while playing in the school. The Patient

reported to OPD almost 4 hours after the injury. The avulsed tooth was air dried and wrapped in a piece of paper. Extra-oral examination revealed no signs of any facial injury. Intraoral examination revealed mixed dentition stage, the maxillary left permanent central incisor was missing and blood clot was found in the alveolar socket. All the other teeth were normal with no carious lesion. IOPA X-ray was taken to rule out any fracture of adjoining hard tissue. (Figure 1)

The tooth was placed in the normal saline to remove any debris. Tooth was placed in 2% Doxycycline solution for 5 min and kept in 2% sodium fluoride solution for 30 minutes later. The parents were counseled about the treatment, consent was taken and treatment was rendered to the patient. Intentional root canal treatment was carried out extra

orally. Access cavity was prepared and the pulp was extirpated, irrigation was done with 2.5% sodium hypochlorite to remove the pulp remanants, Root canal was dried and obturated with gutta percha. Access cavity was restored with Glass ionomer cement and composite restoration Local anesthesia 2% lignocaine was administered to the patient. The tooth socket was irrigated with normal

saline to remove any debris or blood clot. The root canal treated tooth was reimplanted back into the socket and splinted to the adjacent teeth with flexible wire using composite. IOPA was done to confirm proper positioning of the replanted incisor. (Figure 2) Antibiotics and analgesics were prescribed to the patient for 5 days. After 2 weeks the splint was

removed and the patient was asymptomatic. Clinical and radiographic follow up was done at 6, 12, 24 and 72 months. (Figure 3) During the follow ups there was no replacement root resorption and the tooth was asymptomatic.

DISCUSSION

Avulsion is defined as the displacement of the tooth out of the socket thus compromising the aesthetic and biological functions. Replantation is the first treatment of choice for avulsions under favorable clinical conditions as per International Association of Dental Traumatology (IADT) guidelines.4 Favourable outcome of the replantation depends

on various factors such as tooth storage in extra-oral period, time elapsed between the avulsion and replantation, vitality of the periodontal ligament, preparation of the tooth and alveolus before reimplantation.5 Post-replantation root resorption is common complication and can be classified as: replacement root resorption, internal resorption, inflammatory resorption and invasive resorption. The osteoclasts and osteocytes are mainly responsible for

bone resorption and odontoclasts for root resorption. The macrophages and monocytes also play role in the inflammatory resorption.6,7 The extra alveolar dry time and the storage medium affects the treatment outcomes i.e. levels of root

resorption and pulp response. Prolonged air drying of the root is detrimental as it causes loss of vitality of the periodontal ligament cells and dehydration of the vital pulp. The studies have found that extended extra-alveolar time is a good predictor of root resorption. The risk of resorption increases dramatically after 5 minutes of dryness and increasing by 29% for every additional 10 minutes of dryness.8

When extensive damage occurs to the periodontal ligament cells the healing take place by two mechanisms. Healing from the socket wall and healing from adjacent periodontal ligament creating bone and cementum simultaneously. If less than 20% of the root surface is involved, a transient ankylosis may occur, which can later be resorbed due to

inflammatory stimulation. The tooth thus becomes an integral part of the bone remodelling system, osteoclasts and osteoblasts helps in replacement of the resorbed areas of the root with bone. 9

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The replacement root resorption occurs at a slower pace compared to the inflammatory root resorption. Clinically

diagnosis can be made based on high percussive tone and the offended tooth is in infra occlusion as compared to the adjacent teeth. Radiographically, the periodontal ligament space is absent between alveolar bone and the root and direct union is seen. It has been reported that the replacement resorption as the predominant type of post-traumatic external root resorption.

Andreasen et al. reported replacement root resorption in 76% of the 400 avulsed cases.1 Similarly, Soares et al. in 63% and Petrovic et al. in 84% of the cases found replacement root resorption after follow ups in the avulsed teeth.10,11 Donaldson & Kinirons reported more chances of external root resorption when duration of extraoral dry storage

exceeded 15 minutes. 12 In cases of avulsed teeth with a vital periodontal ligament cells, treatment with various agents such as tetracycline has been suggested before replantation as it slows down the resorption process.13 Andreasen and Andreasen recommended that, after root planing the avulsed tooth should be soaked in 2.4% acidulated sodium fluoride solution

(pH 5.5) for 20 minutes before extraoral root canal filling and replantation. It has also been suggested that surface treatment with an enamel matrix derivative gel (Emdogain; Biora AB, Malmo, Sweden) before replantation has the potential to promote regeneration of periodontal ligament cells and therefore may be useful in enhancing periodontal

healing in teeth.14 In this case the root treatment was done with sodium fluoride solution and doxycycline to make the root surface conditioned enough to make a favorable periodontal healing. The consequences of tooth avulsion directly related to the severity and surface area of the inflammation on the root surface. The main aim of the treatment is to limit the extent of the peri-radicular inflammation, thereby making the more

favourable cemental healing rather than inflammatory resorption or replacement resorption. Long term clinical and radiographical follow up would be needed in completely avulsion reimplantaion and luxation cases to make a conclusive evidence of the inflammatory and replacement root resorption.

Figure 1. Intral oral photograph and IOPA showing avulsion of maxillary left permanent incisor

Figure 2. Intral oral photograph and IOPA after reimplantation and splinting with composite and flexible wire

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Figure 3. Follow up IOPA after 12 months (a) 24 months (b) and 72 months (c) showing no inflammatory root resorption

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