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A 4-year-old boy who suffered avulsion of a primary maxillary central incisor was treated with an all-porcelain, resin-bonded retainer. Although prosthetic replacement of primary teeth with resin-bonded prostheses is not common, the method may be beneficial in certain cases.
The success rate of replanted avulsed teeth has been low. This poor success rate results from the use of only one treatment regimen. This treatment regimen, replantation as quickly as possible regardless of circumstances, ignores much of the dental research that shows this regimen to not be efficacious. In addition, the profession has disregarded much of the research that shows many recommended storage media damaging to avulsed teeth. This article reviews the pertinent research on avulsed teeth and recommends a new treatment philosophy of avulsed teeth that delineates 10 treatment categories based on the type of storage medium used, the length of extraoral time, and the stage of development of the root apex.
Every dental practitioner should be familiar with the current treatment recommendations for avulsed teeth. This article has attempted to update the practitioner in both the collection of data and treatment modalities for such traumatic injuries. The long-term prognosis of avulsed teeth has improved both because of the decrease in splinting time, which decreases the incidence of replacement resorption and the use of calcium hydroxide, which produces a better apical seal and decreases the incidence and severity of inflammatory resorption.
A case of successful replantation of a traumatically exarticulated tooth is presented. Avulsed teeth should be replanted immediately after the accident. If this is not possible, the periodontal tissue of the tooth should be protected from drying. Milk has been demonstrated to be a good medium in which the periodontal tissue can survive for as long as six hours whereas teeth stored in the buccal cavity must be replanted in the course of one, or at the latest two hours. Antibiotic treatment should be instituted immediately after replantation, and tetanus prophylaxis should be administered after the usual guidelines. Endodontic treatment should be performed after 10-14 days.
The aim of this study was to investigate the prevalence of teeth with untreated dental trauma among children aged 4-15 years in Dar es Salaam, Tanzania. A sample of 4524 children from three districts of different socio-economic status in the Dar es Salaam area was examined for signs of dental trauma in 1998/99. In 21% of all children examined, at least one type of untreated dental trauma was observed. A high percentage of untreated dental trauma was observed at the ages of 4 and 15 years. The most frequently observed type of dental trauma was enamel fracture (67%) followed by enamel-dentin fracture (26%). A significant gender influence on the occurrence of untreated dental trauma was observed, with more boys (23%) having untreated dental trauma than girls (19%). A higher percentage of untreated dental traumas was observed among children in the district with highest SES (26%) compared to the prevalence in the other two districts (14-17%). The findings of this study show that dental traumas are prevalent among Tanzanian children. Therefore, provision of information to the lay community about the importance of early management of dental trauma, ways of preventing trauma and appropriate handling of avulsed teeth is essential in order to minimize the rate of dental injuries and the related complications.
The prognosis of replanted avulsed permanent incisors depends largely on prompt and appropriate emergency management. The aim of this study was to investigate lay knowledge and attitudes in this respect. Postal questionnaires were sent to all physical education teachers, school nurses and secretaries, attendants in swimming baths and leisure centres and to 220 parents of teenage children in a defined area of North West England. The overall questionnaire response rate was 86.9%. Knowledge of methods of dealing with this problem was generally inadequate in both parents and the other groups. Although 53.6% of respondents claimed to have received first aid training only 3.1% could remember dental injuries being included. There was evidence that dental health education in this field can be effective, since the highest mean knowledge score was found in the 11.5% of respondents who recalled receiving advice from sources such as posters, magazines and newspapers. More than 80% of the respondents stated that they would not want to replant an avulsed incisor themselves, the main reason being lack of knowledge and training. It is suggested that there is a need for potentially effective dental health education in relation to this problem.
A documented case involving the simultaneous avulsion of two maxillary incisors, intraorally and extraorally, was reported. Long-term observations following replantation treatment revealed several interesting clinical features: The prognosis of replanted teeth may be more favorable following intraoral avulsions. The intrusion phenomenon associated with replanted incisors appears to be directly related to replacement root resorption or ankylosis; occlusal forces may be a factor. Teeth extraorally avulsed for a few hours may still provide a useful function, albeit temporary, with replantation treatment. These teeth may not reveal clinical ankylosis or replacement resorption for periods of 1 to 2 years, or possibly longer, following replantation. Long-term studies can help evaluate replantation techniques.
The enamel matrix derivative Emdogain was recently approved for clinical use in a number of countries, including Canada. It has been shown to stimulate regeneration of periodontal ligament following periodontal surgery in adults. This paper reviews pertinent clinical and laboratory studies of Emdogain and describes the protocol and methods used for a longitudinal outcome study of replantation of avulsed permanent incisors in children and adolescents. Application of these methods is described in an illustrative case report of Emdogain use. This paper is meant to inform clinicians and guide those who are instituting similar investigations.
The efficacy of a modified cast-metal resin-bonded splint was evaluated after 14 years in service. The splint was used to immobilize the root-compromised maxillary central and lateral incisors of a teenage male following relapsed orthodontic treatment. The affected teeth were indirectly traumatized, before their eruption, in a bicycle accident that resulted in avulsion of their primary predecessors. The rationale for selecting this treatment modality rather than the alternatives is discussed. The clinical protocol employed during the treatment and subsequent follow-up is described.
This study investigated the occurrence, causes and types of anterior dental trauma treated outside normal clinic and practice hours in Newcastle, Australia. During a 2 1/2-yr period, 233 patients presented for treatment of traumatic injuries to anterior teeth on week nights, weekends and public holidays. The highest occurrence of trauma was in the 18 to 23 yr group (24.9%), followed by the 6 to 11 (23.6%) and the 12 to 17 (22.3%) yr groups. Men sustained injuries more frequently than women in all age groups. The male/female ratio was 2.6:1. The four main causes of trauma were falls (26.6%), sports (18.0%), bicycle accidents (14.2%) and assaults or fights (13.3%). The 233 patients sustained 488 injuries to 95 primary and 373 permanent teeth (n = 468). Maxillary central incisors were the most frequently injured teeth. The mean number of teeth injured per patient was 2.01. Luxation (46.9%) was the most common injury in the primary dentition. In the permanent dentition, crown fractures without pulp exposures (25.0%), followed by luxation (23.5%), were the most common injuries. Avulsion represented 11.5% of all injuries. The findings of this study indicate that anterior dental trauma treated after-hours may be more severe, involve more teeth and affect predominantly older age groups than traumatic injuries treated during normal hours.
Avulsions and intrusions are the most complicated and controversial displacement injuries of permanent teeth. Clinical guidelines published by authorities such as the American Association of Endodontists, the Royal College of Surgeons of England and the International Association of Dental Traumatology are inconsistent. While a certain amount of inconsistency might be expected, some of these guidelines recommend treatments that are experimental or have not incorporated research information from the past 5 years, and in one case the guidelines incorrectly describe the nature of Hank's balanced salt solution. Recent laboratory studies support previous clinical outcome studies in emphasizing that only for teeth replanted within 5 minutes of avulsion is there a chance of regeneration of the periodontal ligament and normal function. Teeth replanted beyond 5 minutes will take another path, that of repair followed by root resorption, ankylosis and eventual extraction. Dentists should explain these outcomes at the time of the replantation decision. Severe intrusions also have predictable outcomes. Teeth intruded beyond 6 mm cannot regenerate a functional periodontal ligament and so are prone to root resorption and eventual extraction as well. In this situation the decision is one of immediate extraction or repositioning, with the understanding that it is inevitable that the tooth will eventually be extracted. Authoritative clinical guidelines available on the Internet provide the clinician with useful outlines for treatment. However, individual inconsistencies stimulate academic controversies and, in some cases, clinical misdirection.
Parents of preschool children with avulsed primary incisors may request replantation. Although dental textbooks uniformly recommend that primary teeth not be replanted, some case reports advocate the procedure. This review of case reports identifies a number of pathological outcomes of replantation and provides information for clinicians and parents on the risks that may accompany replantation.
The purpose of the present study is to assess the teachers' knowledge regarding dental trauma management in two south European cities. A three-part questionnaire comprised of questions on demographic data and knowledge was distributed to teachers in Porto and Istanbul. Seventy-eight teachers participated in the study; 23 had previously had formal dental trauma education. From the teachers interviewed, 58 of them admitted having no knowledge of dental trauma. Concerning knowledge, 29 teachers from Porto and 12 from Istanbul thought dental trauma emergency should be dealt with immediately. Knowledge of optimal storage media for avulsed permanent teeth was especially poor. In the present study, the majority of teachers did not know the importance of tetanus vaccine control in dental trauma. It is recommended that public education targeted at teachers should be carried out to increase dental trauma management knowledge.
Facial trauma in children with immature incisor teeth often results in the complete avulsion of a maxillary permanent incisor because the root is only partially formed and the alveolar bone is still elastic. These teeth may be replanted: the long-term prognosis for replanted incisors has greatly improved because of improvements in our clinical knowledge following the pioneering and painstaking research work of Andreasen and his colleagues.
We aimed to: (i) study the prevalence of root resorption after luxation or avulsion injuries on permanent teeth referred to our dental clinic over a 3-year period; (ii) study the relationship between type of injury and resultant type of resorption complication; and (iii) evaluate success of treatment protocols for various resorption complications. We observed 1943 patients with dental trauma, aged between 2 and 26 years, referred to the Accident and Emergency Department of the Dental Clinic, University of Brescia, from 1st September 1997 to 31st December 2001. Of these, 261 permanent teeth had sustained luxation (n = 188) or avulsion (n = 73) injuries. Permanent teeth luxation and avulsion injuries occurred most often in upper incisors (75%) of patients mostly aged 12-21 years, with males more commonly affected than females (68.3% vs. 31.7%). These cases were followed for 5 years, and complications and response to treatment were recorded. Root resorption was observed in 45 (17.24%) of these cases. Of the 45 cases with resorption, 9 were associated with luxation injury (20%) while 36 (80%) with avulsion. We distinguished 30 cases of inflammatory root resorption (18 transient and 12 progressive) and 15 cases of ankylosis and osseous replacement. When resorption was recognized, quick and effective treatment could still result in an excellent functional and aesthetic outcome for these teeth.
The present paper describes the current treatment philosophy of dislocated or avulsed permanent teeth at our school. Splinting and medication (root canal treatment, systemic antibiotics, etc.) are targeted to minimize the initial inflammatory reaction and to reduce post-traumatic complications such as pulp necrosis and/ or external root resorption.
This study describes the socio-economic burden and attitudes of children and their parents following replantation of avulsed incisors. Records of 80 patients with 99 avulsion injuries treated in a teaching hospital clinic from 1988 to 1999 were reviewed. Mean age at time of injury was 10.6 years (range = 6.6-17.7 years). Complete records for a minimum of 1 year were obtained for 43 patients with 60 replanted incisors. Mean treatment procedures provided during the first year included 5.5 diagnostic periapical radiographs, 1.9 occlusal radiographs, 1.3 pulpectomies, and 2.7 pulp medicament applications. The mean estimated treatment cost and direct time (dentist) for first-year post-trauma management was 1465 dollars CAD and 7.2 h, respectively. Treatment costs were significantly higher during the first year post-trauma for patients who had their incisors extracted (P = 0.04), but there was no significant difference in direct treatment time between the two groups (P = 0.19). Twenty-one patient-parent pairs were surveyed for a number of qualitative factors. Ninety per cent of patients and 86% of parents reported that school and work time was lost. Even after having gone through the painful experience of replantation, the demands of recall, and in some cases, extraction, the majority of patients (67%) and parents (81%) stated that they would have still made the same (replantation) decision. Patient and parent responses were not statistically different (P = 0.453). Almost half the parents stated they would be willing to pay over 2000 dollars CAD to save an incisor. Patients rated retention of an incisor as significantly more important than infraocclusion. This is the first study to quantify the treatment burden of replantation of avulsion injuries exclusively in the pediatric population. This study describes the socio-economic burden and responsibilities of patient/parent and dentist and their role in informed consent.
Oral trauma continues to be a common pediatric emergency, accounting for 150 emergency room dental consultations per year at Children's Hospital in Boston. Children between the ages of 18 months and 2.5 years and between 8 and 11 years are most at risk. Recent advances in the management of these dental emergencies may help children and their families avoid the psychological and financial cost of infection or loss of primary and permanent teeth. Treatment of avulsions in the young permanent dentition remains a common problem, and a universally accepted approach to its management is still evolving. The use of a doxycycline immersion prior to reimplantation by the dentist may be helpful in preventing external root resorption. As always, the best therapy against dentofacial trauma is the pediatrician's support of preventive measures.