Replantation of Avulsed Tooth after Trauma: A One Year ... - IJMD

Replantation of Avulsed Tooth after Trauma: A
One Year Follow-up Study
Swaty Jhamb*, Lalit Bida**
case report
Abstract
Clinical practice has shown that it avulsed teeth are replanted after a delayed extra-alveolar time it compromises the prognosis
of replantation. In case of delayed replantation, the use of adequate media for storage and transportation of avulsed teeth may
improve the prognosis considerably. The case reported in the study is of an accidentally avulsed maxillary right central incisor
that was kept in milk from the moment of trauma until its replantation, 30 minutes later. One year follow-up revealed absence
of root resorption, ankylosis or abnormal mobility, which demonstrates the feasibility of keeping avulsed teeth in milk.
Key words: Replantation, root resorption, ankylosis, prognosis, avulsion
Dentoalveolar traumas are most commonly
observed in children and adolescents,
particularly boys but may affect individuals of
any age. 1,2 Studies have demonstrated that replantation
of avulsed teeth occurs most frequently between one
and 4 hours after avulsion. 1,2 Despite the recognized
therapeutic value of immediate tooth replantation,
clinical practice has shown that most avulsed teeth are
replanted after an extrabuccal time that extrapolates the
adequate conditions for maintenance of the integrity of
periodontal ligament cells. 3 In such cases, wet storage is
considered the best way to store avulsed teeth. 3,4 Some
characteristics of storage medium i.e. pH, osmolarity 5,6
and temperature should be compatible with the survival
of periodontal ligament cells. 4,6 Storage media as Milk,
Hanks balanced salt solution and Viaspan have been
proved to maintain cell viability after long periods. 7
Case Report
A 20-year-old male patient was referred to Dept.
of Conservative Dentistry and Endodontics after
falling from a motorbike and sustaining dental
trauma.
Routine protocol for management of trauma patients
was carried out. On arrival, the patient was examined
for extraoral signs of injury, including swelling and
asymmetry of face and head. Inspection of facial bones
revealed normal mouth opening. No area of ecchymosis,
crepitus or pain on palpation was observed, which
removed the suspicion of underlying fractures.
Intraoral examination revealed avulsion of maxillary
right central incisor (Fig. 1). The patient had difficulty
This article reports, the case of an accidentally avulsed
right permanent maxillary central incisor that was
kept in milk from the moment of trauma until its
replantation, 30 minutes later. The successful clinical
and radiographic findings observed after 1-year followup
are described.
*Senior Lecturer, Dept. of Conservative and Endodontics
**Senior Lecturer, Dept. of Prosthodontics
Dr. HS Institute of Dental Sciences and Hospital, Chandigarh
Address for correspondence
Dr Swaty Jhamb
H.No. 70/1, Sec-38A, Chandigarh
E-mail: drswaty2007@yahoo.co.in
Figure 1. Preoperative photograph.
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Case Report
Figure 2. Tooth stored in milk.
Figure 4. Working length radiograph.
Figure 3a. Replanted tooth in socket.
Figure 5. Post-obturation radiograph.
Figure 3b. Preoperative radiograph with splinted tooth.
Figure 6. Postoperative radiograph after 1-year of
restoration.
in keeping the tooth in the oral cavity so was instructed
to keep the tooth in milk (Fig. 2). The total time elapsed
from the moment of trauma until tooth replantation
was half an hour.
The treatment consisted of replantation of 11 into
socket after meticulous inspection and irrigation of the
avulsed tooth with saline (Fig. 3a). Splinting was carried
from tooth 12 to 11 using resin composite (Fig. 3b).’
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Case Report
Antibiotics were administered for 7 days and 0.12%
chlorhexidine mouth rinses daily were prescribed for
7 days. One week after replantation, the root canal
of 11 was biomechanically prepared using step back
technique (Fig. 4). A Calcium Hydroxide paste was
used as an intracanal dressing and was changed 14 days
later, when splinting was removed. Radiographs were
taken and intracanal medication was changed at 30 and
60 days after replantation. The root canal of the tooth
was obturated at 90 days with Gutta-percha points
and Sealapex that is a Calcium Hydroxide based sealer
(Fig 5). The patient wanted restoration of aesthetics so,
a fixed bridge of metal –ceramic was given. The patient
was kept on continuous recall.
The clinical and radiographic findings after 1-year
follow-up revealed absence of root radiolucency,
absence of root resorption, ankylosis and abnormal
mobility of the replanted tooth (Fig. 6).
Discussion
Milk is mostly used as a storage medium for accidentally
avulsed teeth and therefore, the case reported is
important in the clinical routine or management of
tooth replantation.
Lack of knowledge and possibility of immediate
replantation and unawareness of ideal conditions and
storage media for exarticulated teeth have contributed
to a poor prognosis. Both, the length of extra-alveolar
time and type of storage are significant factors that
can affect the long-term survival of replanted teeth.
Immersion of avulsed teeth in milk at room temperature
preserves the viability of periodontal ligament cells
for upto one hour; whereas, storage in refrigerated
milk is reported to maintain cell viability for additional
45 minutes. 4,8
Irrespective of the type of root surface treatment,
there is consensus in the literature that replanted teeth
should be endodontically treated because the necrotic
pulp and its toxins affect the periodontal ligament
cells through the dentinal tubules and play a decisive
role in the resorption process. 3,9,10 In this case, calcium
hydroxide is the most recommended material for root
canal filling of teeth to be replanted because of its
well-known capacity of controlling the progression of
inflammatory resorption. 11,12
Another aspect of dental replantation is the preparation
of socket, which consists of removal of destructions as
blood clots and bone fragments in order to facilitate
the replantation. 12-15
Contention of replanted teeth is another variable
that might affect the prognosis of tooth replantation.
Basically, it should not interfere with oral hygiene,
allow physiological mobility and remain for a short
time in order to reduce the incidence of ankylosis. 2,16
The goal of antibiotic therapy is to avoid bacterial
proliferation in the area of ongoing process and
contribute to the prevention of inflammatory
resorption. Ideally a broad-spectrum antibiotic should
be administered for seven days. 17
Nevertheless, in the case presented in this paper,
the 1-year clinical and radiographic controls showed
maintainence of root integrity, intact Lamina dura
periradicularly and absence of abnormal mobility,
which are indicative of successful replantation.
Certain precautions were taken while planning the
replantation procedure. The tooth was immersed
in saline prior to replantation to eliminate cell lysis
products resulting from traumatic injury on root
surface, as well as debris and bacteria from saliva. 18-20
Systemic antibiotic therapy was administered and tooth
was endodontically treated to prevent inflammatory
resorption. 21
Root resorption and ankylosis are frequently observed
complications post-replantation. Therefore, despite
the positive results observed after 1-year, clinical and
radiographic follow-up of tooth replanted under the
condition hereby described should be carried for a
longer period.
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