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Delayed replantation of an avulsed maxillary premolarwith open
apex: A 24 months follow-up case report
Ravi K. S., Pinky C.1, Shikhar Kumar2, Amit Vanka3
Department of Preventive Dental Sciences, Division of
Pedodontics and Preventive Dentistry, College of Dentistry, King
KhalidUniversity, Abha, Kingdom of Saudi Arabia, 3Division of
Pedodontics and Preventive Dentistry, Faculty of Dentistry, Ibn
Sina NationalCollege of Medical Sciences, Jeddah, Kingdom of Saudi
Arabia, 1Pediatric Dentistry, Farooqia Dental College &
Hospital, Mysore,Karnataka, 2Pediatric and Preventive Dentistry,
University College of Medical Science, New Delhi, India
that will cause tooth loss.[5] Andreason has reportedthat if the
tooth has been out of the mouth for more
than 2 h, there is 95% chance of external resorption.
[6,7]
Nevertheless, if managed appropriately, avulsedteeth with viable
PDL when reimplanted can remainfunctional for some years. This
article describes the rarecase of management of an immature avulsed
premolarwith an extra-alveolar dry storage of more than 3 h.
Case Report
A healthy 11-year-old boy reported to the Departmentof Pediatric
Dentistry with a chief complaint of missingupper right back tooth
and lip laceration. Historyrevealed that patient has had bicycle
accident about3 h ago resulting in loss of upper right back
tooth.Intraoral examination revealed lip laceration alongwith
clinically missing maxillary right first premolar[Figure 1].
Following which parents were asked tovisit the site of accident to
find the avulsed tooth ifpossible and meanwhile periapical
radiographicinvestigation carried out revealed no evidence ofany
associated hard tissue injury. The tooth wassubsequently found at
the site of accident with soilcontamination [Figure 2]. Examination
of avulsedtooth revealed intact crown and root with wide apical
Address for correspondence:Dr. Pinky C,Department of Pediatric
Dentistry, Farooqia Dental College& Hospital, Tilak Nagar,
Mysore - 570 021, Karnataka, India.Email:
[email protected]
Case Report
ABSTRACT
Avulsion of permanent teeth is most serious ofall dental
injuries and accounts for 1-16% of alltraumatic injuries, of which
maxillary incisors are
most commonly involved. However, in this report arare case of
isolated avulsed immature premolar hasbeen described. The patient
had reported more than3 hours after the trauma with a tooth stored
in drycondition and soil contamination. The prognosisdepends on
measures taken at the place of accidentor the time immediately
after avulsion. Replantationis the treatment of choice, but cannot
always beperformed immediately. An appropriate emergencymanagement
and treatment plan is important forgood prognosis. In this report
stepwise managementof an avulsed immature maxillary premolar
withextended period of dry storage has been described
followed up for a period of 2 yrs.KEYWORDS: Avulsion, delayed
replantation,immature premolar
Introduction
Avulsion accounts for 0.5-16% of traumatic injuries inthe
permanent dentition.[1,2] Avulsion of permanentteeth can occur at
any age, but is most common in youngpermanent dentition due to
roots being incompletelyformed and resilient periodontium and
bone.[3]
Prognosis depends on measures taken at the place ofaccident or
the time immediately after avulsion.[4]Whena tooth is avulsed,
attachment damage, pulp necrosis,and small localized cemental
damage occurs. If theperiodontal ligament (PDL) left attached to
the rootsurface does not dry out, the negative consequencesof tooth
avulsion are usually minimal. However, ifexcessive drying occurs,
following replantation thesePDL cells will elicit a severe
inflammatory response,with physiologic bone re-contouring on the
root surface
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DOI:
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Journal of Indian Society of Pedodontics and Preventive
Dentistry | Jul-Sep 2013 | Vol 31| Issue 3 | 202
tissue, and thoroughly debrided with physiologicsaline solution.
The tooth was gently replanted withdigital pressure, occlusion was
evaluated and wiresplinted with acid etch composite resin attached
toadjacent teeth for a period of 2 weeks [Figures 3 and4]. Patient
was administered 5 days course of 250mg amoxicillin thrice daily to
prevent infection andadvised to be on soft diet. Oral hygiene
instructions
were given and chlorhexidine mouthwash (Hexidine2%, ICPA Health
Products LTD, India) recommendedtwice a day for 2 week. Splint was
removed after 2weeks with no post-operative clinical or
radiographiccomplications and patient was followed-up regularlyat
6, 12, 18, and 24 months [Figures 5-8]. Tooth showedno clinical
symptoms such as mobility, periodontalpocket or color change. Dull
note on percussion wasyielded at 24 months follow-up visit and
periapicalradiographic examination showed no sign of externalroot
resorption.
Discussion
Best available treatment for avulsed teeth is
immediatereplantation, but for a variety of reasons this can be
foramina and necrotic dried remnants of periodontaltissue due to
extensive extraoral dry storage ofover 3 h. Patient had bimaxillary
protrusion andwas referred to the Department of Orthodonticsfor
possibility of extraction of other premolarsand orthodontic
correction. Despite advisability oforthodontic treatment and poor
prognosis associatedwith replantation of an avulsed tooth,
parents
declined any kind of dental intervention and wantedthe tooth to
restored back. Treatment plan wasestablished to carry out root
surface treatment andextraoral root canal treatment (RCT). The
tooth rootwas treated with triple antibiotic paste consistingof
ciprofloxacin, metronidazole, and minocycline inthe ratio of 3:1:1
mixed with propylene glycol for aperiod of 10 min. Conventional
enlargement andcleaning of root canal was performed. The canalswere
dried with sterile paper points and obturatedwith Gutta Percha
(Dentsply Maillefer Swiss made,Ballaigues) and the root ends were
sealed with glassionomer cement (GC Fuji IX, Tokyo, Japan).
Under
local anesthesia the socket was gently curetted toremove any
coagulum, granulation and pathologic
Figure 1: Pre-operative intraoral photograph showing an
avulsedright first premolar
Figure 3:Post-operative intraoral photograph after replantation
andsplinting with composite resin wire splint
Figure 2:Photograph of an avulsed premolar with soil
contamination
Figure 4:Post-operative intraoral radiograph following
splinting
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difficult for nonprofessional person and teeth areoften covered
with debris. Clinical evidence suggeststhat macroscopic
contamination on the root surfaceresults in significant higher
percentage of teeth healingwith ankylosis following avulsion and
replantation.An explanation for this is that any foreign
materialand bacteria will increase the extent and duration
ofinflammatory response.[8]
In the present report, the time elapsed from occurrenceof trauma
up to emergency care was more than 3 h,worsened by dry storage and
soil contamination on
root surface. The anticipated healing of pulpal andperiodontal
tissues was extremely low as per scientificliterature. However,
despite unsatisfactory conditionsreplantation was the treatment
option due to parentsinsistence and young age of the patient as the
youngpermanent tooth loss leads to severe arrest of alveolarbone
formation in a growing child. Alveolar ridgewould be narrow and
difficult to restore in future witheither a bridge or implant. Most
conservative approachfor managing the avulsed teeth is to reimplant
them assoon as possible.[9]
The prerequisite for functional healing of an avulsedtooth is
absence of infection. Early infection relatedcomplications derive
from infected pulp space leadingto tooth loss. Hence,
pre-replantation extraoral RCT wasperformed in this case to prevent
a common complicationof inflammatory root resorption, that occurs
morerapidly in young patients as the dentinal tubulesare more
patent and readily transmit inflammatoryproducts from pulp to the
root surface.[10,11]
In this report, the root surface of premolar sufferedextensive
damage from improper storage conditions.
Acc to Trope, when severe additional damage cannotbe avoided and
osseous replacement of the rootis considered certain, steps are
taken to slow thereplacement of root by bone to maintain the
toothin mouth for as long as possible.[12] Root surfacetreatment
with various agents such as tetracycline,dexamethasone, stannous
fluoride, sodium fluoride,and tetracycline have been suggested by
variousauthors.[13-16] In this case, root surface treatment
wascarried out with triple antibiotic paste
containingciprofloxacin, metronidazole, and minocycline mixed
Figure 5:6 months follow-up radiograph Figure 6:12 months
follow-up radiograph
Figure 7:18 months follow-up radiograph Figure 8:24 months
follow-up radiograph demonstrating good bonehealing without any
root resorption
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with propylene glycol to decontaminate the surfaceand exert
prolonged bactericidal effect on PDL.[17]According to Makkes etal.
uncontaminated devitalizedtissue cause low/no inflammatory
reaction, andthereby accounting for good periodontal healing inthis
case at 24 months follow-up.[18]
Experimental studies in non-human primates have
demonstrated that rigid splinting, i.e., immobilizationor a
prolonged splinting period may lead to extensivePDL healing
complications, such as dentoalveolarankylosis or external root
resorption (replacementresorption.[16] Hence, splinting technique
that allowsphysiologic movement of the tooth during healing,and
that is in place for a minimal time period shouldbe used.[9]
Wire-composite resin splint was used inthis case for a period of 2
weeks as it allows good oralhygiene maintenance and well tolerated
by patient.
An avulsed tooth will be exposed to bacterialcontamination both
extraorally and intraorally andreduction in bacterial inflammatory
stimulus by the
use of antibiotics may have some role in improvingperiodontal
and pulpal healing.[19]Patient in this reportwas prescribed 5 days
course of amoxycillin as thebacteria found within the alveolar
socket of avulsedteeth have been found to be sensitive to
penicillinbased antibiotics in an investigation carried out byParry
etal.[20]
During 2 years follow-up, patients esthetics andocclusal
function have been maintained. Clinically,dull note on percussion
was yielded at last follow-up visit, but radiographically there was
no evidenceof any resorption. The expected outcome in this casewas
replacement resorption, but radiographic normal
appearance of root could be attributed to limitation ofintraoral
radiography, i.e., unable to visualize the teeth3-dimensionally.
However, the patient is still underfollow-up to determine the
ultimate fate of this toothreplanted under unfavorable
conditions.
Conclusion
Despite the fact that tooth had extended extra-alveolardry
storage, root surface treatment with triple antibioticpaste
rendered the root surface more resistant toresorption, indicating
the possibility of its long survivalin oral cavity. This case
report highlights the need forin depth investigation of root
surface treatment options
and the importance of replanting avulsed teeth evenwhen the
conditions are not very favorable.
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How to cite this article:Ravi KS, Pinky C, Kumar S, Vanka A.
Delayed replantation of an avulsed maxillary premolar with
open
apex: A 24 months follow-up case report. J Indian Soc Pedod
Prev
Dent 2013;31:201-4.
Source of Support:Nil, Conflict of Interest:None declared.
