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RESEARCH AND REVIEWS: JOURNAL OF DENTAL SCIENCES

Replantation of Avulsed Permanent Anterior Teeth: A Case Report.

Abu-Hussein Muhamad1*, Watted Nezar2, and Abdulgani Azzaldeen3.
1Department of Pediatric Dentistry, University of Athens, Athens, Greece.
2Department of Orthodontics, Arab American University, Jenin, Palestine.
3Department of Conservative Dentistry, Al-Quds University, Jerusalem, Palestine.

Case Report
Received: 18/08/2014 ABSTRACT
Revised : 13/09/2014
Accepted: 17/09/2014 Tooth avulsion in the permanent dentition constitutes a
dental emergency. Replantation of the avulsed tooth restores
*For Correspondence aesthetics and occlusal function shortly after the injury. This article
describes the management of a 12-year old male with four avulsed
Department of Pediatric anterior maxillary permanent teeth. The avulsed teeth were
Dentistry, University of replanted and root canal treatment carried out after a short fixation.
Athens, Athens, Greece. The result obtained was very satisfactory and the teeth remain in
good functional status one year after replantation. Early treatment
Keywords: Permanent and regular attendance to clinic following replantation is an
teeth, avulsion, important factor for good result.
replantatio, PDL

INTRODUCTION

Traumatic injuries have become more common these days and the incidences of dental trauma
have become comparatively higher. Trauma might involve both the hard and soft tissues. The success of
the treatment of traumatized teeth revolves around the status of periodontium since it is a vital structure.
Hence treatment of traumatic injuries are quite complex and at times requires a multi disciplinary
approach [1,2,3,4,5].

Avulsion is known as complete displacement of tooth from the alveolus. The incidences are 1% to
16% in permanent teeth and 7% to 13% in primary teeth in school going children age. Replantation for
avulsed teeth should be carried out immediately. The maxillary incisors are frequently avulsed teeth while
lower jaw is less affected [1,5,6].

The prognosis for avulsions improves if the periodontal ligament (PDL) cells are preserved [7,8,9].
Soder et al. and Andreasen have shown that when a tooth is avulsed from the socket, PDL cells on the root
surface will remain viable if they are hydrated [5,10]. Vital PDL cells can reattach when replanted and
viability is best maintained if the tooth is replanted within the first 15-20 minutes after avulsion [11]. Tissue
transport medium, such as Viaspan® (DuPont Pharmaceuticals, Wilmington, DE)Fig.1 and Hank’s Balance
Salt Solution (HBSS) (Mediatech, Herndon, VA) Fig.2 have exceptional ability to keep cells alive and are
considered to be superior storage media. Readily available storage media for an avulsed tooth, in order of
preference, are milk, saliva and saline [12,13,14]. Another commercially available, antibiotic-free, protective
medium is the emt TOOTHSAVER® (SmartPractice, Phoenix, AZ) Fig.3. Water is not recommended
because the hypotonic environment damages the PDL cells. One study measured the average number of
vital human lip fibroblasts remaining after 2-168 hours of storage in 3 media. This study showed that after
12 hours, Viaspan® was effective at keeping 72.9% of cells vital while HBSS and milk maintained the
vitality of 70.5% and 43.4% cells, respectively [12].

Researchers have shown that relatively good success rate was achieved when the tooth is
replanted immediately. Therefore this technique for replantation assumes that avulsed tooth should be
located quickly and replanted at the site of injury itself if possible before reaching to the dentist. If not the

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tooth has to be Fig.4 immediately placed in a suitable transport medium like saliva, buccal vestibule, milk,
coconut water etc. In a tooth with an open apex there are possibilities of revascularization of the pulp as
well as continued root development [1,2,7,12].

The speed with which the avulsed tooth is replanted is the most important factor for success [8,9].

There are several possible effects on the root surface and attachment apparatus of an avulsed
tooth.

 Normal PDL healing: complete regeneration of the PDL. Damage cannot be clinically or
radiographically detected.
 Surface resorption: the crushing injury is restricted, inflammatory response is limited and repair
can occur with replacement cementum. Clinically, the tooth presents aymptomatic, with normal
mobility and percussion sounds. Radiographically, there are no periradicular radiolucencies and
no loss of lamina dura [15].
 Ankylosis and replacement resorption: occurs when excessive drying damages the PDL cells and
evokes an inflammatory response that results in the replacement of the cells with alveolar bone.
Dentoalveolar ankylosis is the term used when precursor bone cells populate the damaged root
resulting in a direct bone-root contact void of an attachment apparatus. Replacement resorption
occurs when osteoclasts in contact with the root resorb dentin that is eventually replaced with
new bone by osteoblasts. Clinically, the tooth will be immobile and have a high-pitched sound
when percussed. Radiographically, there is absence of the lamina dura. With replacement
resorption, the root surface appears moth-eaten [15]. In young patients, infraocclusion or
submergence results when replacement resorption interferes with the tooth’s ability to move with
the normal downward growth of the alveolar process.

External inflammatory root resorption: the result of a combination of severely damaged

attachment and bacterial contamination of a necrotic pulp. It may rapidly progress. Clinically, it presents
as radiolucencies in the root and adjacent bone [15].

Case Report

A 12 year old boy reported to our pediatric dental clinic with avulsed maxillary right central incisor,
lateral incisor and canine after one hour of injury. The teeth were soaked in a water. There was swelling
and lacerations on upper lip and lower lip. His parents and boy, both were very anxious and disturbed due
to loss of front teeth. They were assured that his teeth could be saved and they were relaxed. The teeth
were rinsed with water and placed in a saline solution. Fig.5

Local anesthesia was given and as much care was taken not to hold teeth by root to save the
vitality of periodontal ligament. The debris of dust and dead tags of the tissues over root were removed
with wet sponge of saline very gently. Then sockets were prepared for replantation. Sockets were gently
aspirated and irrigated with saline, then the teeth were replaced in the sockets and manually compressed
to its original position Knocked out tooth. If a permanent tooth has been knocked out of its socket
(avulsed), immediate attention is required.

Then the teeth were splinted with ligature wire and interdental wiring was performed along with
light cure composite resin. Patient was kept under antibiotics and analgesics. He was advised for tetanus
consultation within 48 hours Fig.7. Patient was also advised not to bite onsplinted teeth and to take soft
diet and ask to maintain good oral hygiene by proper brushing and chlorhexidine rinses12%. In the present
case patient was tried for replanation in an attempt to revitalize pulp. Patient was called after six to eight
weeks because of partly involvement of alveolar bone Fig.8,9.

After eight weeks splinting was removed and it was found that teeth were strongly adhered to the
socket and there was no mobility at all Fig.10. Patient was complaining of mild pain while percussion. After
clinical and radio graphical evaluation root canal treatment was performed. Patient was recalled at interval
of every six months. There was no sign of pain, mobility found within six months. Patient was kept under
observation for further evaluation Fig.11,12.

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DISCUSSIONS

A traumatic dental injuries are emergencies that the dentist must be able to assess rapidly and
manage appropriately. The determination of treatment plan is very important in case of avulsed teeth. In
present study a 12 year old boy with avulsed right maxillary incisors was treated with replanation
technique. After thorough investigation of vitality of teeth the root canal treatment was done after six
weeks of replanation not at the time of replanation with the hope to revasularize the pulp because pulpal
necrosis is usually demonstrated after three weeks. The results in this case were satisfactory clinically as
well as radiographically and patient was kept under observation for further study [1,2,4,5,6].

The patient will generally present with one of three clinical scenarios

 The tooth has already been replanted. Do not extract the tooth. Simply cleanse the area with
water spray, saline, or a 0.1% chlorhexidine mouth rinse.
 The tooth has been kept in an appropriate storage media or the extra-oral dry time has been less
than 60 minutes. The contaminated root surface should be cleaned with saline. If needed, the
tooth can be stored in a storage media such as HBSS or Viaspan while a trauma examination is
quickly performed. Assessment of the socket and surrounding teeth and bone by palpating and
radiographing the injured site will determine whether the socket is intact and suitable for
replantation. Fractures of the socket wall should be repositioned prior to replantation. Coagulum
can be removed from the socket with a stream of sterile saline to facilitate slow, slight digital
pressure replantation. Fig.13,14,15
 The tooth has an extra-oral dry time of more than 60 minutes. The root surface PDL cells are not
expected to survive. Assess the injured socket and surrounding area for fractures and reposition
prior to replantation. Remove the coagulum with sterile saline only. Do not curette the socket.
The PDL should be removed by soaking the tooth for 5 minutes in 2.4% sodium fluoride solution
acidulated to a pH of 5.5. This procedure will remove the damaged tissue that would otherwise
initiate an inflammatory response [7,8]. The use of an enamel matrix protein, Emdogain® (Biora,
Malmö, Sweden), is now recommended because recent studies demonstrate that it may make the
root more resistant to resorption and promote the growth of a new PDL from the socket [16,17]. The
socket can be filled with Emdogain® prior to replantation of a tooth with an extra-oral dry time of
greater than 60 minutes (7). It may also be valuable in cases where the extra-oral dry time is 20-
60 minutes [8]. Revascularization of the pulp in an avulsed tooth with a mature, closed apex is not
possible. The root canal treatment can be done prior to replantation if the extra-oral dry time is
greater than 60 minutes, but care must be taken to keep the canal space bacteria-free. Fig.16,17

Pulpal tissue of teeth with closed apices cannot survive an avulsion injury and must be removed.
Endodontic treatment for all avulsed permanent teeth with a closed apex should be initiated, and calcium
hydroxide placed at 7-10 days. Usually after one month, when an intact lamina dura can be traced around
the root surface, the calcium hydroxide can be replaced with gutta-percha. If endodontic treatment has
been delayed, and there is radiographic evidence of root resorption, calcium hydroxide is needed for an
extended period of time and the status of the lamina dura should be checked every 3 months. Fig.18.

The same concerns for viability of the PDL on avulsed permanent teeth with open apices apply to those
with closed apices and treatment guidelines are also based on the tooth’s extra-oral dry time [18,19].

 The tooth has already been replanted. The area should be cleaned with water spray, saline or a
0.1% chlorhexidine mouth rinse.
 The tooth has been kept in a storage media for less than 60 minutes. Clean the contaminated
root surface with a stream of sterile saline. Prior to replanting, soak the tooth in a solution of
doxycycline (1mg/20ml saline). Examine the socket for suitability, remove the coagulum with
sterile saline, and replant slowly with slight digital pressure.
 Current guidelines recommend that teeth with open apices and extra-oral dry times of greater
than 60 minutes not be replanted. Studies and debate are ongoing to determine if there are
situations when replanting a tooth can maintain the height and width of the alveolar bone in a
growing child.

A replanted tooth is determined to have a satisfactory outcome if it is asymptomatic, has normal

mobility and eruption pattern, normal sound to percussion, and tests positive to vitality tests. It is
important to note that it may take up to 3 months to respond positively to vitality testing. Radiographically,

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continued root development is expected. An unsatisfactory outcome includes symptoms, high-pitched
percussion sound, infra-occlusion, arrested development of the root and a pulp lumen unchanged in size.
At the first definite signs of failure, the necrotic pulp must be removed and apexification treatment
initiated [7,8].

Figure 1: ViaSpan fluid

Figure 2: HBSS 1X Hanks' Balanced Salt Solution is designed to maintain pH and osmotic balance and to provide cells
with water and essential inorganic ions.

Figure 3: Save-A-Tooth - Tooth Saver

Figure 4: Dental avulsion

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Figure 5: Tooth transferred to solution of sodium fluoride

Figure 6: Pre-operative intraoral periapical radiograph showing extensive bone loss

Figure 7: Splinted from maxillary primary canine to canine with a Flexible Niti wire.

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Figure 8: Post-operative intraoral periapical radiograph taken after 7 days, to ascertain alignment of tooth and apical
positioning

Figure 9: Post-operative intraoral periapical radiograph taken after 30days, to ascertain alignment of tooth and apical
positioning

Figure 10: Post-operative intraoral periapical radiograph taken after 3 months, to ascertain alignment of tooth and
apical positioning

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Figure 11: Intraoral periapical radiograph 6 months post-operative

Figure 12: Esthetic outcome after splint removal, core placement and composite buildup

Figure 13: Knocked out tooth. If a permanent tooth has been knocked out of its socket (avulsed), immediate attention
is required.

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Figure 14: The tooth has been kept in a medium of physiologic osmolarity (saliva, milk, saline, or tissue culture
medium). The extraoral time is less than 60 min.

Figure 15: The tooth has been replanted prior to the patient arriving at the dental office or clinic

Figure 16: The tooth has not been kept in a medium of physiologic osmolarity (saliva, milk, saline, or tissue culture
medium), eg, tap water, or dry storage for the first 60 minutes posttrauma or more.

Figure 17: Delayed replantation has a poor long-term prognosis. The periodontal ligament has dried out or necrosed
and cannot heal to normal periodontal attachment. A replacement resorption (ankylosis) is inevitable. The tooth may
still be replaced, not least for psychological reasons and for gaining time in decision making for definitive treatment

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Figure 18: Protocol for emergency management of an avulsed incisor

CONCLUSION

The success of avulsed tooth is directly proportional to the time and storage type of the tooth.
Clinical studies have shown that teeth replaced within 20-30 minutes have the best prognosis, so
reattachment success will be much higher. The choice of storage for preserving traumatically avulsed
teeth is important for the success of future replantation. Ideally, the tooth should be stored in milk,
saliva,physiological saline and clean water. Follow-up appointments: include splint removal and initiation
of endodontic treatment, if required, at one week. Clinical and radiographic exams should be scheduled at
2-3 weeks, 3-4 weeks, 6-8 weeks, 6 months, 1 year and annually for 5 years.

REFERENCES

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