001 – Management of Avulsed Permanent Incisor

Avulsion is sudden separation of a tooth from it socket caused by trauma. Normally happen to the player without wearing a sport mouthguard in the body contact sports like ruby or basketball,  when the front teeth been knocked, the incisors will luxated or avulsed.

For adult, we can either replanted the avulsed tooth or if the condition wasn’t allow, then the missing tooth can be replaced by dental implant or removable prosthesis. We are more concern when this incident happen in young school children, because they are still in growing stage, keeping the tooth will help the development of dento-alveolar and the jaw bone. In addition, it help to maintain the symmetrical face development and space for future replacement.

There are three factor that determine the success of replantation.

1. Successful replantation healing can occur if there is only minimal damage to the pulp and the periodontal tissue. The avulsed tooth can be hold by crown only without touching the root to ensure the periodontal ligament do not damage during the transportation to clinic.

  1. Rinse the avulsed tooth under cold water and then keep it in patient’s saliva (or parent), saline or milk.
  2. Go to dental clinic immediately for replantation, the chances of success is high when the avulsed tooth is out from socket less than 60 minutes. Less success if more than 60 minutes and no survival after 120 minutes.

In the process of replantation, the dentist will rinse the periodontal ligament (the root) and apical are with normal saline, re-contour the socket if necessary, then replant with gentle finger pressure, splint the avulsed tooth to the adjacent teeth with a stainless steel wire and resin composite for 7-10 days. If the avulsed tooth is out from socket more than 60 minutes, the dentist need to do root canal treatment to remove the pulpal tissue and dress with canal medicament to prevent internal root resorption. If it is less than 60 minutes, the root canal treatment may defer few days later, prior to splint removal. The patient need to take antibiotics and keep the oral hygiene by using chlorhexidine mouthwash, sometime anti-tetanus injection may needed. The patient are advice for soft diet for a week. The splint should be removed after 7-10 days to prevent ankylosis (root fused directly to alveolar bone if the periodontal ligament is damage) which may caused root resorption.

 The research shown that 5 year pulp survival rate for open apex replanted tooth is 30% but no survival pulp for closed apex replanted tooth. Research also shown that almost all replanted tooth have root resorption after 5 years. Although the 5 years outcome doesn’t sound encouraging, but please remember the aims of replantation; keeping the tooth to help the development of dento-alveolar and the jaw bone, and to maintain the symmetrical face development and space for future replacement.

What to expect after 5 years?

  1. Complete root resorption, the tooth become loose and need to replace by either removable partial denture or dental implant.
  2. Partially root resorption, the tooth still intact and function, keep in view.
  3. Discolouration of crown, if the root condition is still retainable, may consider veneering or crowning.
  4. Ankylosed and in alignment, no treatment required, monitoring the root.
  5. Ankylosed and not in good alignment, may need orthodontic alignment, or extraction and replacement.

What to expect if the avulsed tooth not replanted for young children?

  1. Loss of space, caused facial asymmetry. Replacement become difficult.
  2. Alveolar bone loss or not developed.
  3. Midline of teeth shifted from facial midline.
  4. Tilted of adjacent tooth.
  5. Gap appear in adjacent teeth.

Clinical Case Report

A 14 years old Malay boy suffered from sport injuries. The upper left central incisor avulsed after been knocked by his friend’s elbow during a basketball game in school. He didn’t wearing any sport mouthguard during the game.

Thanks to his mum (dental nurse). The avulsed tooth was managed properly. He keep his tooth under his tongue on the way to my clinic. (Not recommended for younger child, scare they might swallow it! May keep in a clean bag /container filled with saliva, or inside parent’s mouth if you are keen) He managed to reach my clinic within 30 minutes after the incident. The tooth been clean with saline and replanted with gentle finger pressure.

The avulsed tooth been splinted to adjacent teeth with stainless steel wire and resin composite. Antibiotics and analgesic prescribed, patient will then have to be on soft diet for a week.

Review after 10 days. The soft tissue healed and the avulsed tooth successful replanted. The splint removed and the pulp of the tooth was removed by doing root canal treatment.

Review after 1 years. The tooth are in good function without any sign and symptom.

Review after 3 years. The tooth having slight discoloration but no root resorption observed. Internal bleaching carry out to whitening the tooth.

 

Prepared by,

Dr Goon Yong Por,
Dental Surgeon
BDS, FICD, FADI, FICCDE
Cert Implantology

Principal,
Union Dental Surgery

Chairman,
Malaysian Dental Association Northern Zone