Scientific papers

Australian Dental Journal 1997;42:(6):361-6

Paediatric Dentistry Avulsion: Case repor ts

J. E. Rutar, BDSc(Qld), GCEd(Qld)*
Case 1 In August 1993 a nine year old boy presented for emergency treatment. Approximately half an hour earlier the principal of a local primary school contacted the clinic regarding a student who had sustained dental injuries. Immediate first aid treatment was initiated at the school and an avulsed tooth was retrieved and placed in a milk solution. The childs parents were contacted and arrangements made to transport the child to the clinic for immediate treatment. Upon arrival at the clinic, the child and parents were visibly upset. Bleeding was apparent from the oral cavity. The avulsed tooth was presented in a coffee cup containing milk. Questioning revealed that the child had tripped and fallen face first onto a school path. There was no history of previous trauma, no loss of consciousness, and the medical history was unremarkable. Examination of the patient revealed superficial facial abrasions. Centric occlusion was not disturbed and there was no limitation of mandibular movement on opening, closing and lateral excursion. Intra-oral examination revealed a class II crown fracture of tooth 21, absence of tooth 11 and mobility of teeth 12 and 22. Pre-operative radiographs revealed immature apices of teeth 12, 21 and 22, complete avulsion of the upper right permanent central incisor and no signs of tooth fragments intraorally. No alveolar bone fracture was noted. Examination of tooth 11 revealed a small incisal crown fracture, open apex and contamination of the root surface. Immediate dental management included gentle removal of foreign material on tooth 11, replantation, placement of a flexible splint on the upper permanent incisors and glass ionomer dressings on teeth 11 and 21 (Fig. 1). This proved to be a difficult and challenging procedure considering the patients apprehension to dental treatment. Each step of the treatment was explained to establish rapport with
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Abstract Children may present at a dental surgery for management of oro-facial injuries. Most general dental practitioners are able to handle straightforward cases but referral may be required for complex injuries. Successful healing following tooth avulsion depends on the amount of damage to teeth and supporting structures, emergency treatment, and follow-up treatment. All of these play a role in the long-term prognosis of avulsed teeth.
Key words: Avulsion, central incisors, apexification, trauma, case reports. (Received for publication March 1996. Revised June 1996. Accepted June 1996.)

Introduction Traumatic injuries to teeth and their supporting structures in children pose a treatment challenge to the general dental practitioner. Luxation, crown fracture, root fracture, crown-root fracture and avulsion are the injuries to deciduous and permanent teeth encountered in practice. For deciduous teeth, such injuries may result in damage to the developing permanent successor, while trauma to permanent teeth may compromise their long-term prognosis. The primary aim of management of traumatic dental injuries to immature teeth in children is to maintain the vitality and viability of the teeth. This may involve professional observation or intervention depending on the type and severity of trauma. Avulsions are a significant traumatic injury presenting in general dental practice and require prompt, definitive treatment and follow-up care. This paper presents three case reports outlining the treatment stages following complete avulsion of immature permanent teeth.

*Dental Officer, Brisbane South Regional Health Authority, Queensland.

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Case 1 Fig. 1.Labial view of teeth following replantation and splint application. Fig. 2.Intra-oral appearance one week post-operative. Fig. 3.Radiograph of tooth 11 dressed with calcium hydroxide. Fig. 4.a Marginal gingivitis and resin composite restorations on teeth 11 and 21. b Soft tissue lesion associated with tooth 21.

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the patient. At the completion of emergency treatment the parents were informed of the treatment undertaken, future treatment needs, possible sequelae and prognosis. Postoperative instructions were given to the patient and parents. The patient was referred to his medical practitioner for tetanus and antibiotic prophylaxis.
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Clinical examination one week later revealed healing of facial and intra-oral tissues (Fig. 2). The splint was removed and weekly reviews made. At a subsequent appointment signs of pulpal necrosis were evident on the upper right permanent central incisor. The root canal was cleaned, dressed with a gluco-cortico-steroid antibiotic compound and
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Case 1 Fig. 5.a Occlusal radiograph showing apexification of tooth 11. b Periapical radiograph of tooth 21 showing periapical rarefaction. Fig. 6.Clinical appearance of extirpated pulp.

sealed. Subsequent clinical and radiographic reviews revealed no signs of pathosis. Acid etch composite resin restorations were placed on the upper permanent central incisors. In October 1993 the upper right central incisor was cleaned and redressed with calcium hydroxide (Fig. 3). A clinical and radiographic review in December 1993 revealed no signs of pathosis and arrangements were made for early review in February 1994. The patient was eventually reviewed in April 1994. Clinical examination revealed poor oral hygiene and pathology associated with the upper left permanent central incisor (Fig. 4). Radiographic examination revealed continued root development of teeth 12 and 22, apexification of tooth 11 and periapical rarefaction of tooth 21 (Fig. 5). At a
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subsequent appointment necrotic pulpal tissue was extirpated from tooth 21 (Fig. 6). The root canal was cleaned and dressed with a gluco-cortico-steroid antibiotic compound. Resolution of soft tissue pathology occurred within two weeks. In June 1994 the upper left permanent central incisor was redressed with calcium hydroxide. A review appointment scheduled for September 1994 was not kept and all attempts to contact the patient have proved unsuccessful. Case 2 In March 1993 a ten year old boy presented for a consultation appointment. His mother presented a referral letter from a dental practitioner for follow363

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Case 2 Fig. 7.a Radiograph of empty alveolus. b Radiograph of tooth 11 with diagnostic file during initial pulp extirpation. Fig. 8. Radiograph of tooth 11 dressed with calcium hydroxide. Fig. 9.Radiograph of tooth 11 with a size 140 gutta percha point. Fig. 10.Radiograph of completed obturation of tooth 11.

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Case 3 Fig. 11.Clinical view of colour and position of upper permanent incisors. Fig. 12.Palatal view of maxillary right permanent lateral incisor. Fig. 13.Periapical radiograph of maxillary right permanent central and lateral incisors.

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up dental treatment. Enclosed information and radiographs revealed a history of complete avulsion of the upper right permanent central incisor three weeks previously (Fig. 7). The upper right permanent central incisor had been replanted within half an hour, splinted, and the patient referred to his medical practitioner for tetanus and antibiotic prophylaxis. One week later the pulp was extirpated and dressed with a gluco-cortico-steroid antibiotic compound. Medical history was unremarkable and the oral cavity was asymptomatic. Clinical and radiographic examination showed the tooth to be asymptomatic. The splint was removed and the mother was informed of future treatment needs. At a subsequent appointment the root canal was cleaned and explored with files. A diagnostic radiograph was taken with a size 110 file at a predetermined length. The tooth was dressed with calcium hydroxide (Fig. 8). The patient was recalled until radiographic evidence of apexification was noted. The canal was then entered and a file
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confirmed the presence of an apical hard tissue barrier. A size 140 gutta percha point was length controlled for apical seat verification (Fig. 9). The tooth was subsequently obturated with gutta percha and root canal cement using a vertical condensation technique and restored (Fig. 10). A review six months later by a colleague revealed the tooth to be asymptomatic with no signs of pathosis. Case 3 In January 1993 an 11 year old boy presented for an orthodontic consultation. His mother expressed concern about his malocclusion. The medical history was unremarkable. Questioning revealed a history of regular dental attendances, a persistent thumbsucking habit, and dental trauma 18 months previously. Dental trauma consisted of the complete avulsion of the upper right permanent central and lateral incisor. The child received emergency and follow-up treatment over a three-month period. Exact details could not be ascertained immediately.
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The patient was concerned about the discoloration of two teeth. Clinical examination revealed a permanent dentition with a Class II buccal segment relationship and anterior open bite. Discoloration and infraocclusion of the upper right permanent central and lateral incisor was noted (Fig. 11). Gingivitis was present labially, while palatally there was hyperplastic tissue associated with the upper right permanent central incisor. The palatal surface of teeth 11 and 12 revealed an endodontic access. A pink discoloration on the distal aspect of tooth 12 was noted (Fig. 12). The upper right permanent central and lateral incisors disclosed a metallic sound on percussion. Radiographs were taken and these revealed gutta percha root canal fillings of teeth 11 and 12 and resorption of the root of the upper right permanent lateral incisor (Fig. 13). In view of these findings a specialist orthodontic consultation was arranged. Discussion Information on current concepts and management of oro-facial injuries is readily available from journal articles and classical texts. Exarticulation or complete avulsion occurs when a traumatic injury displaces a tooth from its socket. Such injuries in children occur at home, school, or elsewhere and are produced from falls, playground accidents, bicycle accidents, and sporting injuries.1,2 Andreason1 has described three types of root resorption in avulsed teeth: 1. Surface resorption 2. Inflammatory resorption 3. Replacement resorption. Inflammatory and replacement resorption are progressive lesions while surface resorption is selflimiting. Inflammatory resorption can be halted by removal of necrotic pulpal tissue and subsequent obturation of the root canal. Replacement resorption results in the replacement of tooth substance with bone. Long-term follow-up of tooth avulsion and replantation has been reviewed.3-7 The majority of avulsed teeth succumb to external root resorption and pulpal necrosis.4 However, cases have been reported demonstrating long-term success.8-10 Recently Andreason4-7 reported on the follow-up of 400 avulsed teeth and concluded: 1. Pulpal healing occurred in 34 per cent of cases. 2. Periodontal healing occurred in 24 per cent of cases. 3. Continued root development in immature teeth is dependent upon the amount of damage to Hertwigs epithelial root sheath.
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4. Thirty per cent of replanted teeth were later extracted. 5. Immediate replantation is the single most important factor in pulpal and periodontal healing. Lay and professional knowledge of emergency management of avulsed teeth has been investigated.11,12 These surveys have identified deficiencies in knowledge and advocated the introduction of educational campaigns to broaden the lay publics knowledge of emergency procedures. Conclusion The prognosis of avulsed teeth cannot be guaranteed. Every attempt should be made to replant teeth in children as it acts as an ideal space maintainer during the childs growth period. Reviewing of cases is essential as unfavourable sequelae can occur years after treatment. Acknowledgement Approval from the Regional Director, Brisbane South Regional Health Authority, for publication of this article is gratefully acknowledged. References
1. Andreason JO. Essentials of traumatic injuries of teeth. Copenhagen: Munksgaard, 1990. 2. Stockwell AJ. Incidence of dental trauma in the Western School Dental Service. Community Dent Oral Epidemiol 1988;16:2948. 3. Mackie IC, Worthington HV. An investigation of replantation of traumatically avulsed permanent incisor teeth. Br Dent J 1992;172:17-20. 4. Andreason JO, Borum MK, Jacobsen HL, et al. Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications. Endod Dent Traumatol 1995;11:51-8. 5. Andreason JO, Borum MK, Jacobsen HL, et al. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol 1995;11:59-68. 6. Andreason JO, Borum MK, Jacobsen HL, et al. Replantation of 400 permanent incisors. 3. Factors related to root growth. Endod Dent Traumatol 1995;11:69-75. 7. Andreason JO, Borum MK, Jacobsen HL, et al. Replantation of 400 permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11:76-89. 8. Abrams RA. Tooth replantation: 11-year follow-up. Aust Dent J 1987;32:427-9. 9. Barry GN. Replanted teeth still functioning after 42 years: Report of a case. J Am Dent Assoc 1976;92:412-3. 10. Fuss Z. Successful self-replantation of avulsed tooth with 42 year follow-up. Endod Dent Traumatol 1985;1:120-2. 11. Raphael SL, Gregory PJ. Parental awareness of the emergency management of avulsed teeth in children. Aust Dent J 1990;35:130-3. 12. Stokes AN, Anderson HK, Cowan TM. Lay and professional knowledge of methods for emergency management of avulsed teeth. Endod Dent Traumatol 1992;8:160-2.

Address for correspondence/reprints: School Dental Therapist Training Centre, 150 Park Road, Yeronga, Queensland 4104.
Australian Dental Journal 1997;42:6.