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| CASE REPORT |
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| Year : 2014 | Volume
: 4
| Issue : 2 | Page : 91-94 |
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Delayed replantation after prolonged dry storage
Anita Rao, Apoorva Kommula, Muralidhar Tummala
Department of Conservative Dentistry and Endodontics, Mamata Dental College and Hospital, Giriprasad Nagar, Khammam, Andhra Pradesh, India
| Date of Web Publication | 19-May-2014 |
Correspondence Address:
Anita Rao
Department of Conservative Dentistry and Endodontics, Mamata Dental College and Hospital, Giriprasad Nagar, Khammam, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1658-5984.132730
Management of tooth avulsion in the permanent dentition often presents a challenge. 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 patient with an avulsed maxillary permanent incisor that had been air-dried for about 40 h. The replanted incisor retained its esthetic appearance and functionality 1 year after replantation, yet the long-term prognosis is not good because of progressive replacement root resorption. Keywords: Replantation, resorption, tooth avulsion
How to cite this article:
Rao A, Kommula A, Tummala M. Delayed replantation after prolonged dry storage. Saudi Endod J 2014;4:91-4 |
| Introduction | |  |
Tooth avulsion is defined as total displacement of the tooth out of its alveolar socket. [1] It is a complex injury that affects the pulp tissue, periodontal ligament and alveolar bone possibly also affecting the apical bundle. [2] Avulsion of permanent teeth occurs most often in children 7 to 9 years old and the maxillary central incisors are the teeth most commonly affected. [1] It accounts for 0.5 to 16% of all traumas to the permanent teeth and 7 to 13% to the deciduous teeth. [3] Tooth replantation is the best treatment option for tooth avulsion in the permanent dentition. [2] The percentage of success of tooth replantation has been observed to be low, ranging from 4 to 50%. [4] Extra-alveolar dry time and the storage media used to transport the tooth are critical factors for successful and long-term outcomes. [5] Clinical reports have shown that the prognosis is best for teeth replanted within five minutes of avulsion. [6],[7],[8],[9] The success of delayed replantation depends on the vitality of the cells remaining on the root surface, [10] the length of extra oral dry time. [4] Prolonged non-physiological storage of avulsed teeth before replantation results in total necrosis of the periodontal ligament, and healing occurs either by replacement root resorption or inflammatory root resorption. [9] Nevertheless, if managed properly, avulsed teeth with non-vital periodontal ligament can be replanted and will remain functional for some years. [11]
| Case report | | |
A 20-year-old male patient, reported to the Department of Conservative Dentistry and Endodontics, Mamata Dental College, Khammam with his knocked out tooth rolled in a paper. The patient had the injury due to falling in a road traffic accident from a motorcycle one day prior to his visit to the department. On extra oral examination there were lacerations on the left forehead, left cheek region and below left nostril which were sutured a day after the incident. Swelling was seen with upper lip region [Figure 1]. On intraoral examination, it was found that the socket of the knocked out left maxillary permanent incisor was dry with blood clot in it [Figure 2]. All of the adjacent teeth showed positive response to vitality tests. He presented with a class I skeletal relationship with fair oral hygiene and no carious lesions were detected clinically. Examination of the avulsed tooth revealed that the crown was intact and that the root had a nearly closed apex, but the root surface was covered with dried remnants of periodontal tissue. It was estimated that the avulsed tooth had been kept dry for about 40 h. An intra oral periapical radiograph and a maxillary anterior occlusal radiograph were obtained, and no other hard-tissue injury was detected in that region [Figure 3]a]. The available treatment options were explained to the parent, and it was decided to replant the avulsed incisor as an intermediate treatment. Local anesthesia was achieved by administering 2% Lignocaine with Adrenaline (1:200000). A surgical curette was used to remove the blood clot, granulation tissue and to induce fresh bleeding. The socket was regularly irrigated with Chlorhexidine gluconate (2% Chlorhexidine Gluconate CHX, Dentachlor, Ammdent, India) and saline. The root of the avulsed tooth was planed to remove the necrotic periodontal tissue. Root canal treatment was planned extra orally and was then filled with gutta-percha points (Dentsply, India) and AH plus (Dentsply, India) sealer. Later, root apex of 2 mm was resected and root end filling was done using Glass-ionomer cement (Fuji III, GC International, Tokyo, Japan). Surface treatment of the root was done using fluoride application i.e. Acidulated Phosphate Fluoride Gel (FLUROVIL, Vishal Dentocare Pvt. Ltd. India) for 20 min and then rinsed with saline. The tooth was then finally placed into the socket and held under pressure in order to achieve the proper placement of the tooth. While keeping the tooth under pressure the teeth were etched in order to place the splint for immobilizing the tooth. Etching was done with 37% phosphoric acid (Scotch bond™ Universal Etchant 3M ESPE, UK). All the teeth were then rinsed with the avulsed tooth still under pressure . Bonding agent (Adper™ Single Bond 2 Adhesive 3M ESPE, UK) was applied on all the teeth and cured. A stainless steel rectangular wire of 25 gauge was used to splint the teeth along with composite for 6 weeks. An intra oral periapical radiograph was taken to check for the proper placement of the replanted incisor [Figure 3]b]. A 7-day course of systemic penicillin, Amoxicillin 500 mg, thrice daily was prescribed, and the patient was referred to the medical practitioner for an anti-tetanus booster. The patient was instructed to have soft diet up to 2 weeks and to brush teeth with a soft toothbrush after each meal. Patient was prescribed Chlorhexidine gluconate (Dr. Reddy's, India) mouth wash for maintaining the oral hygiene. The patient was seen again at 2, 6 and 12 weeks after replantation and then half-yearly. Pulp vitality of adjacent teeth was checked at every follow up visit. All of the adjacent anterior teeth remained symptomless and showed no sign of pulpal death or root resorption. After one year follow up the radiograph revealed that the replacement resorption has started with replacement of periodontal space by osseous tissue [Figure 3]c]. | Figure 3: Pre-operative radiograph of the socket (a), radiograph after splinting (b) and post- operative follow up radiograph afterone year (c)
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| Discussion | | |
Avulsion of tooth takes place when a tooth directly sustains trauma which displaces the tooth from the socket. In clinical studies, teeth replanted within five minutes after avulsion had the best prognosis and the chance of pulpal and periodontal healing was inversely related to the stage of root development and the period of dry storage. [12] A previous study by Kinirons et al. [13] indicated that the risk of resorption increases dramatically after five minutes of dryness, with the probability of resorption increasing by 29% for every additional 10 minutes of dryness. In the optimal scenario, the avulsed tooth should be replanted immediately or should be stored in a physiological medium such as saline for only a short period before replantation. [14],[15] In the present case report, the time elapsed from the occurrence of trauma up to emergency care was 40 h, worsened by the dry storage of the tooth, conditions reported in the scientific literature as unfavorable for a good prognosis. The treatment objective was to retain the avulsed incisor to maintain esthetic appearance and occlusal function, to prevent inflammatory root resorption and to achieve periodontal healing with replacement root resorption. Therefore, the avulsed incisor was splinted to the adjacent teeth with rigid wire for 6 weeks to facilitate rapid, solid ankylosis. [5],[11],[16] The root of the avulsed incisor was also filled extra orally. Given that replacement root resorption was inevitable after the prolonged period of dry storage, it was thought that further drying and handling of the root surface was unlikely to worsen the prognosis. [15] The extra oral dry time was prolonged due to which there will be presence of blood clot and necrotic debris within the socket; this may prevent the complete seating of the tooth in the socket. Cobankara and Ungor [17] recommended that before replantation, the root apex should be resected allowing complete seating of the tooth in the socket. In cases of avulsed teeth with non-vital periodontal ligament, treatment with various agents such as tetracycline before replantation has been suggested in the hope of slowing down the resorption process. [18] Andreasen and Andreasen [1] recommended that, after planing of the root to remove necrotic periodontal tissue, such teeth be soaked in 2.4% acidulated sodium fluoride solution (pH 5.5) for 20 min before extra oral root filling and replantation. However, the fluoride solution was unavailable, instead topical fluoride gel (acidulated phosphate fluoride) was available in the department and keeping in mind the advantages of fluoride application, we decided to use topical fluoride gel for root conditioning. Systemic antibiotics given at the time of replantation are recommended to prevent bacterial invasion of the necrotic pulp, thereby avoiding inflammatory resorption. [19] The long-term prognosis for the replanted incisor in the case presented here is not good. Teeth replanted after 60 min of dry storage become ankylosed and are resorbed within 7 years in young patients, whereas teeth replanted under similar conditions in patients older than 16 years may remain functional for considerably longer periods. [20]
| Conclusion | | |
In conclusion, in cases of avulsed permanent teeth with prolonged non-physiological storage, replantation should be performed if the patient and his or her parents are aware of the outcomes and request such treatment, although the risk of progressive replacement resorption and subsequent tooth loss is high.
| References | | |
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[Figure 1], [Figure 2], [Figure 3]
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