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Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 199-203

Delayed management of avulsed mandibular incisor teeth: 4-year follow-up

Department of Restorative Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication21-Aug-2017

Correspondence Address:
Tariq Abuhaimed
Department of Restorative Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_96_16

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Tooth avulsion represents one of the most challenging dental traumas in terms of emergency and definitive treatment. Immediate replantation is recommended for best prognosis. However, delayed replantation is usually inevitable, which usually leads to root resorption and often times tooth loss. This case reports the management of an 8-year-old boy who presented 4 months after replantation and repositioning of avulsed mandibular right central and lateral incisor teeth (#41 and #42) and luxated mandibular left central incisor tooth (#31) with established root resorption. Although the prognosis of the avulsed teeth was poor, 4-year follow-up revealed functional healing of tooth #42 and partial healing of tooth #41 and arresting of the resorption. Tooth #31 showed canal obliteration. Currently, all teeth are asymptomatic and have normal percussion and mobility. In conclusion, saving an avulsed tooth of a child for few years would be very important for future prosthetic plans.

Keywords: Avulsion, canal obliteration, delayed replantation, external and internal root resorption, luxation

How to cite this article:
Abuhaimed T. Delayed management of avulsed mandibular incisor teeth: 4-year follow-up. Saudi Endod J 2017;7:199-203

How to cite this URL:
Abuhaimed T. Delayed management of avulsed mandibular incisor teeth: 4-year follow-up. Saudi Endod J [serial online] 2017 [cited 2022 Dec 7];7:199-203. Available from: https://www.saudiendodj.com/text.asp?2017/7/3/199/213485

  Introduction Top

Management of dental traumas is usually challenging due to their nature on the face. They usually leave a big psychological impact on the parents and the child. Among all dental injuries, teeth avulsion accounts for 0.5%–3% of children 7–10 years old.[1] Avulsion is a serious injury involving the pulp, periodontal ligaments (PDL), and alveolar bone. It usually occurs as a result of fall injuries, especially in children with mixed dentition due to the short roots and resilient periodontal support.[2]

The healing of replanted teeth depends on the viability of the PDL cells at time of replantation. Plenty of reports agreed on that the best prognosis occurs with immediate replantation.[2],[3],[4],[5],[6] However, in most cases, this does not happen because of the circumstances of the trauma and lack of knowledge of the attending personnel.[5],[7]

Replantation of teeth beyond 5 min has been defined by Andreasen et al. as delayed replantation, which is usually followed by complications including replacement resorption and inflammatory resorption.[4] This critical time has been extended by others to 15 min.[3] With dry storage time more than 60 min, 90%–100% of teeth showed signs of resorption or ankylosis.[1],[8] The ultimate goal in avulsed teeth management is to maintain the teeth and the supporting bone during growth of the child to avoid the complication of tooth loss and bone resorption.

The purpose of the current paper was to report a 4-year follow-up of management of avulsed mandibular central incisors 4 months postreplantation.

  Case Report Top

An 8-year-old boy reported to our dental clinic in Jeddah, Saudi Arabia, complaining of mild pain related to lower anterior teeth during biting. The parent reported that the child had an accident 4 months ago in Germany, while he was playing at playground and fell on his face. The mandibular right central (#41) and lateral (#42) incisor teeth were avulsed and fell on the ground and the mandibular left central incisor tooth (#31) was luxated. After the accident, the parents called the emergency, which reported shortly after the call. The emergency team was not familiar with the management of avulsed teeth. They wiped the teeth with an antiseptic solution, wrapped them with napkin, and headed to the nearest hospital but there was no dental staff so they were referred to the nearest dental school at Munich, Germany, at which there was no specialist available. The emergency doctor washed, disinfected the teeth, and managed to replant them after 3 h extraoral dry time. He also placed a fixation wire and prescribed antibiotics. The parents reported that no radiographs were taken. Moreover, no extraoral management to the teeth surfaces was performed. The family was supposed to travel the next day back to Saudi Arabia and was advised to visit a specialist at home. Three weeks after arriving, they visited a private dental clinic for follow-up. The examining doctor reported that there was external root resorption on teeth #41 and #42, which showed negative response to vitality test. Tooth #31 was vital and had no signs of resorption [Figure 1]. The parents were informed that the prognosis was poor and intervention would be hopeless. The fixation wire was removed with no further treatment. The patient was advised to follow-up after 1 month. At the follow-up visit, again dental management was declined and a follow-up appointment after 1 month was given.
Figure 1: Preoperative radiograph showing mid and apical inflammatory root resorption on teeth #41 and #42

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The parents eventually decided to seek another opinion where they showed up at our clinic almost 4 months after the accident.

Clinical examination showed neither signs of extra- or intra-oral injuries nor dental fractures. Mobility of the lower right incisors was mild. Other teeth had normal mobility. Percussion test revealed mild tenderness on the lower incisors with normal sound. Sensibility test indicated no response on teeth #41 and #42 while tooth #31 showed normal response.

Radiographic examination [Figure 1] showed apical radiolucency and apical and midroot resorption in teeth #41 and #42. Tooth #31 showed does not show any periapical changes. Teeth #41 and #42 had relatively wide apices, which could be related to apical break down.

Although the prognosis of the treatment was poor due to the long extraoral dry time (>60 min) before replantation and the lack of ideal management, the decision was to save the teeth under the parent's request and the young age of the patient.

Under complete isolation, teeth #41 and #42 were accessed. Working length was taken using Root ZX II apex locator (Morita, Irvine, CA, USA). The root canals were shaped with hand file (Dentsply, Tulsa, OK, USA), irrigated with 6% sodium hypochlorite (Vista Dental Products, St. Paul, MN, USA), and filled with calcium hydroxide thick mix (ApexCal, Ivoclar Vivadent, Liechtenstein, Germany). The access cavities were restored with Fuji II Glass ionomer cement (GC America, Alsip, IL, USA). Due to the presence of inflammatory root resorption and periradicular lesion, the decision was to leave the intracanal medication for 6 months [Figure 2]. The patient was given postoperative instructions and was advised to follow-up after 3 months for regular examination and 6 months to complete the treatment.
Figure 2: Postoperative radiograph after initiation of root canal treatment and placement of calcium hydroxide

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At 6-month follow-up visit, the patient was symptoms free and healing signs were seen in the radiograph. Therefore, the root canal treatment was carried on. The canals were cleaned out and filled completely with gutta-percha points (Dentsply, Tulsa, OK, USA) and Root Canal Sealer (Pulpdent, Watertown, MA, USA) and the access cavities were filled with Z100 composite resin (3M, St. Paul, MN, USA) [Figure 3]. At the same visit, it was noticed that the root canal space of tooth #31 was obliterated and developed internal resorption lesion in the coronal third [Figure 3]. Therefore, root canal treatment was initiated to arrest the resorption process. On opening the tooth, the canal was completely obliterated and it was only possible to negotiate the coronal third of the root, which was connecting to the internal resorption lesion. The canal was irrigated with sodium hypochlorite and filled with calcium hydroxide intracanal medication. After 2 weeks, the canal was filled with ProRoot white mineral trioxide aggregate (Dentsply, Tulsa, OK, USA) [Figure 4].
Figure 3: Postoperative radiograph (6 months recall). Arrow indicates internal resorption

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Figure 4: Radiograph showing tooth #31 filled with mineral trioxide aggregate

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At 12 months follow-up visit [Figure 5]a, teeth were asymptomatic and mobility was normal. Radiographic examination showed a decrease in size of the periapical lesion, especially around tooth #42. In the following visits, 2, 3, and 4 years [Figure 5]b,[Figure 5]c,[Figure 5]d, the lesion around tooth #42 was gradually healing until completely healed. The inflammatory resorption was arrested and functional healing of the PDL was seen making a uniform PDL space. Although resorption has stopped, there was partial healing of the lesion around tooth #41 where the apical radiolucency still existed. Tooth #31 showed arresting of internal resorption and complete obliteration of the canal space. On percussion, all teeth sounded normal. Photograph of the patient at 4-year follow-up shows normal height and color of the incisor teeth [Figure 6]. The patient will be annually followed up until his growth is completed and appropriate treatment will be performed if needed.
Figure 5: Follow-up radiographs: (a) 1 year, (b) 2 years, (c) 3 years, and (d) 4 years. Arrows indicate functional healing of periodontal ligament with uniform periodontal ligament space

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Figure 6: Follow-up clinical photograph, 4-year postreplantation

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  Discussion Top

Avulsion is the total displacement of teeth from their sockets leading to severance of PDL and neurovascular vessels. Most avulsion injuries are seen in children at an age with incomplete facial growth. Teeth loss at this early age may hinder facial and physiological development of children. It is of high value to save avulsed teeth until development is complete.

Under ideal conditions, i.e., immediate replantation, complete healing of the PDL is possible.[4] However, in most cases of avulsion, addressing the facial injuries and the limited knowledge of the personnel attending the accident lead to delayed replantation.[5] Consequently, root resorption is expected.[3],[4],[9],[10] Therefore, the management of avulsed teeth usually aims to stopping or slowing the inflammatory process, which may eventually lead to tooth loss.

The current study represents a 4-year follow-up of delayed replantation of permanent mandibular incisors with established root resorption.

At the time of replantation, the avulsed teeth had been kept in dry napkin for collective time more than 3 h. Washing and disinfection were the only steps performed prior replantation. If the emergency team or hospital managed the situation properly, the teeth would have been replanted within short time or at least kept in wet solution, which in turn would result in better prognosis for the teeth.[2] Considering the total extraoral dry time, which was more than 60 min, the ideal treatment would have been root surface management and extraoral root canal treatment.[1] After 60 min of dry time, the PDL and the pulp are most likely necrotic and probably contaminated with foreign bodies and bacteria, which are the main cause of replacement and inflammatory resorption of the roots.[5] Clinical evidence suggested that contamination on the root surface led to significantly higher percentage of teeth healing with ankylosis following avulsion and replantation.[3] The protocol in this situation is to slow down the resorption process. This is achieved by scraping the dead PDL and treating the root surface with sodium fluoride or antibiotics.[11] Furthermore, timely disinfection of the pulp space is important to eliminate the possibility of passage of bacteria from the pulp space to the periradicular space.[12] This is especially true knowing that dentinal tubules are wide open due to the loss of cementum after trauma and scraping of the root surface.

When the patient presented to our clinic, it was already 4 moths postreplantation. The teeth were symptomatic and radiographic examination showed inflammatory root resorption of teeth #41 and #42 in addition to periradicular lesion around them. It was shown that the risk of inflammatory resorption was increased with increased time elapsed between pulp extirpation and replantation.[12],[13] Time is very critical in the management of such cases before replantation as well as after replantation.[12] When resorption starts, the process will be expected to continue unless proper management takes place by eliminating the cause of inflammation through disinfection of the pulp canal space.[14]

Although the prognosis was poor due to the unfavorable conditions of the case and the age of the patient, it was attempted to save the teeth upon the parent's request. Teeth loss in such a young age would be troublesome.

Therefore, to eliminate the inflammatory stimulus, root canal treatment as soon as possible in attempt to stop or slow the resorption process was planned.

The root canal was initiated immediately. As an intracanal medication, the canals were filled calcium hydroxide. It was shown that calcium hydroxide has the ability to disinfect the root canal and dissolve the canal content, which in turn would slow the osteoclast activity.[15] According to literature, calcium hydroxide could be left for short- (1–3 weeks) or long-term (up to 24 months). Trope et al. reported that long-term calcium hydroxide treatment may be more effective than short-term of established inflammatory root resorption.[15] However, extended time up to 24 months has been shown to result in lower prognosis than final treatment with gutta-percha.[7] Therefore, the decision was to use 6 months treatment of calcium hydroxide to arrest the condition of the root.

At 6-month follow-up, periapical radiographs showed internal resorption and root canal obliteration of tooth #31. In extrusive injuries, healing of teeth with incompletely formed apices involves reestablishing the continuity of PDL as well as revascularization of the pulp. However, pulp canal obliteration is the usual end result of revascularization consisting with the current case.[2] Furthermore, as a result of the trauma and injury to the cementum layer, coronal pulp inflammation due to the open dentinal tubules, could trigger internal resorption of the tooth.[16]

On follow-up visits, tooth #42 showed repair-related resorption by reestablishment of the PDL and restoring the PDL space. Similarly, tooth #41 showed repair on the distal aspect while periapical radiolucency still existed. Although the size of the lesion did not increase in 4-year period, close monitoring should be performed.

According to literature, there are three types of periodontal healing posttraumatic root resorption: Repair-related resorption, also termed functional healing, inflammatory resorption, and replacement resorption (ankylosis). Several studies showed that the most common healing with prolonged dry storage is replacement resorption,[4],[6],[8],[9],[17] which did not occur in the current case. This may be related to the delayed initiation of the treatment. When calcium hydroxide is placed within 7–10 days posttrauma, it was shown to induce ankylosis.[18] It may be advantageous to delay or avoid intracanal medication with calcium hydroxide to avoid ankylosis.

Although the prognosis of the case was poor and healing was not expected, the outcome of the treatment is considered successful. Even if the teeth were saved for few years, this would be very important for future prosthetic plans. The child should be monitored annually until adolescence.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.  Back to cited text no. 1
Andreasen JO, Backland LK, Flores MT, Andreasen FM, Andersson L. Traumatic Dental Injuries: A Manual. 3rd ed. Copenhagen: Wiley-Blackwell; 2011. p. 8-79.  Back to cited text no. 2
Donaldson M, Kinirons MJ. Factors affecting the time of onset of resorption in avulsed and replanted incisor teeth in children. Dent Traumatol 2001;17:205-9.  Back to cited text no. 3
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11:76-89.  Back to cited text no. 4
Petrovic B, Markovic D, Peric T, Blagojevic D. Factors related to treatment and outcomes of avulsed teeth. Dent Traumatol 2010;26:52-9.  Back to cited text no. 5
Boyd DH, Kinirons MJ, Gregg TA. A prospective study of factors affecting survival of replanted permanent incisors in children. Int J Paediatr Dent 2000;10:200-5.  Back to cited text no. 6
Barrett EJ, Kenny DJ. Survival of avulsed permanent maxillary incisors in children following delayed replantation. Endod Dent Traumatol 1997;13:269-75.  Back to cited text no. 7
Chappuis V, von Arx T. Replantation of 45 avulsed permanent teeth: A 1-year follow-up study. Dent Traumatol 2005;21:289-96.  Back to cited text no. 8
Finucane D, Kinirons MJ. External inflammatory and replacement resorption of luxated, and avulsed replanted permanent incisors: A review and case presentation. Dent Traumatol 2003;19:170-4.  Back to cited text no. 9
Rao A, Kommula A, Tummala M. Delayed replantation after prolonged dry storage. Saudi Endod J 2014;4:91-4.  Back to cited text no. 10
  [Full text]  
Bjorvatn K, Selvig KA, Klinge B. Effect of tetracycline and SnF2 on root resorption in replanted incisors in dogs. Scand J Dent Res 1989;97:477-82.  Back to cited text no. 11
Bastos JV, Ilma de Souza Côrtes M, Andrade Goulart EM, Colosimo EA, Gomez RS, Dutra WO. Age and timing of pulp extirpation as major factors associated with inflammatory root resorption in replanted permanent teeth. J Endod 2014;40:366-71.  Back to cited text no. 12
Kinirons MJ, Boyd DH, Gregg TA. Inflammatory and replacement resorption in reimplanted permanent incisor teeth: A study of the characteristics of 84 teeth. Endod Dent Traumatol 1999;15:269-72.  Back to cited text no. 13
Andersson L, Bodin I, Sörensen S. Progression of root resorption following replantation of human teeth after extended extraoral storage. Endod Dent Traumatol 1989;5:38-47.  Back to cited text no. 14
Trope M, Moshonov J, Nissan R, Buxt P, Yesilsoy C. Short vs. long-term calcium hydroxide treatment of established inflammatory root resorption in replanted dog teeth. Endod Dent Traumatol 1995;11:124-8.  Back to cited text no. 15
Andreasen FM. Pulpal healing after luxation injuries and root fracture in the permanent dentition. Endod Dent Traumatol 1989;5:111-31.  Back to cited text no. 16
Pohl Y, Filippi A, Kirschner H. Results after replantation of avulsed permanent teeth. II. Periodontal healing and the role of physiologic storage and antiresorptive-regenerative therapy. Dent Traumatol 2005;21:93-101.  Back to cited text no. 17
Lengheden A, Blomlöf L, Lindskog S. Effect of delayed calcium hydroxide treatment on periodontal healing in contaminated replanted teeth. Scand J Dent Res 1991;99:147-53.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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