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- 1. MANAGEMENT OF AVULSED PERMANENTANTERIOR TEETH IN CHILDREN
- 2. OBJECTIVE To provide evidence-basedguidance in the management of avulsed permanent anterior teeth in children To disseminate and reinforce knowledge on the management of avulsed permanent anterior teeth among healthcare professionals To provide timely and appropriate management of avulsed permanent anterior teeth by healthcare professionals 2 .
- 3. INTRODUCTION Avulsion of atooth is defined as the complete displacement of a tooth out of its socket. It is associated with severed periodontal ligaments and may be associated with fractures of the alveolar socket. Figure 1: Avulsed anterior permanent teeth 1
- 4. 2 Aetiology Falls, collisions andaccidents at home, school or playground due to common childhood activities such as contact sports, cycling, swimming and fights. (In young children, the relatively resilient alveolar bone provides only minimal resistance to extrusive forces)
- 5. Prevalence Most frequently seenin children between the ages of 7 – 9 years. Up to 30% of children have been exposed to accidental injuries to the teeth by the age of 15 years. About 0.5% - 16% of all accidental injury to the teeth involves avulsion or total displacement of the tooth out of its socket. This mishap can occur at any time and place and the most frequently avulsed teeth are the upper anterior permanent central incisors.
- 6. PATHOPHYSIOLOGY Extrusive forces impingingon the teeth, when severe enough, can cause a tooth to be displaced out of its socket. For this to happen, the periodontal ligaments would have ruptured, leaving remnants on the cementum of the root and the inner walls of the alveolar socket. The vessels entering the pulp through the apical foramen would also have been severed with cessation of blood supply to the pulp. The extent of injury sustained by the periodontal ligament and the pulp, and the subsequent healing of these tissues will depend on the extra-alveolar period i.e. the time the tooth remains out of its socket and the handling of the tooth.
- 7. Rootapex Periodontalligament Toothrootwithanouter layerof cementum Toothcrownwithan outer layerofenamel Gingiva Alveolarbone Figure2: Anatomy of tooth and supporting structures Bleedingin socket Ruptured blood vessels Tornperiodontal ligamentinsocket Damaged periodontal ligamentin root surface Figure 3: The avulsed tooth 3
- 8. Pulpal Reactions •Pulp canbe completely revascularised in immature avulsed teeth. •Factors that influence the pulpal reaction : Width of the apical foramen The storage medium The extra-alveolar period *The chances of revascularisation are greatest when the apical foramen is wider, the extra-alveolar time is short and the tooth is stored in an appropriate storage medium. The absence of bacterial contamination is also considered to be an essential requirement for complete revascularisation.
- 9. Periodontal Ligament Reactions Threetypes of healing modalities have been described depending on the severity of injury sustained by the periodontal ligament. •Functional healing Complete regeneration of the periodontal ligament along the root surface usually takes about 7 – 14 days. This will only occur if the periodontal ligament cells remain vital. •Healing with inflammatory resorption Histologically, it is characterised by areas of resorption in bone and the adjacent root surface. This may progress till the tooth becomes mobile and is extruded. Clinically, the percussion tone is dull. The patient may present with pain. •Healing with replacement resorption Histologically, fusion of bone and root surface is observed. Clinically, the tooth is not mobile (ankylosed) and gives a high percussion tone. It may become infra-occluded over time. This occurs when there is failure of regeneration of the periodontal ligament.
- 10. 5 Importance Of Replantation •Servesas a natural space maintainer whilst growth occurs. •Enables alveolar height to be preserved. •Simplifies future prosthetic rehabilitation by means of bridge or implant placement, in the event of failure of the replanted tooth.
- 11. 6 Contraindications For Replantation . Inthe following instances replantation may not be advisable: The avulsed tooth has extensive caries and evidence of advanced periodontal disease The alveolar socket has major comminutions or fractures Immature avulsed permanent tooth with short root and wide open apex. Uncooperative patients Excessively dry or inappropriate storage
- 12. Replantation is absolutelycontraindicated in the following instances: Where other injuries are severe and require preferential emergency treatment or intensive care. -For example a child with concomitant severe head injury or polytrauma which requires immediate urgent attention When there is compromised medical history, avulsed teeth should not be replanted in cases where doing so would place the patient at risk. -Examples are patients with heart lesions who are at risk of bacteraemia with a possibility of developing infective endocarditis or patients with depressed immunity as in acute lymphoblastic leukemia. When the immature permanent tooth has a short root with wide open apex and there is prolonged dry extra-alveolar time. -If the dry extra- alveolar time is long then replacement resorption is inevitable. As replacement resorption occurs at a higher rate in a young person and these teeth already have a short root, the prognosis is very poor. In most of these cases replantation is not warranted.
- 13. 7 MANAGEMENT Stages inmanagement of avulsed permanent anterior teeth: o Emergency management at the site of injury o Storage and transportation medium o Management at dental clinic/emergency department - History taking - Replantation - Splinting - Medication Follow up
- 14. Emergency Management atSite of Injury The philosophy for treatment success of avulsed teeth is to replant the tooth immediately or as soon as possible. Time is the critical factor. 1. Pick the tooth by its crown. Do not handle the root 2. Check to see if the root surface is clean 3. If dirt is present on the root, rinse gently with cold fresh milk, saline or tap water in order of preference. 4. Do not scrub dirt off the root 5. Place the tooth into its socket 6. Get the child to bite on a clean, folded handkerchief to keep the tooth in place 7. Go to the nearest dental clinic as soon as possible
- 15. 8 Storage And TransportationMedium The best storage medium is the tooth socket itself. Other recommended transport media are: Fresh or UHT milk (cold) and not condensed or powdered milk Physiological saline (0.9% sodium chloride) Saliva The tooth may also be placed in the buccal sulcus (between the cheek and teeth) of the child. However this is not recommended for fear of accidental swallowing or aspiration in a young child pH balanced cell preserving solutions such as Hank’s Solution/ Emergency Tooth Preserving System, Emdogainand Viaspan
- 16. Management at DentalClinic/Emergency Department Pre-operative Assessment History -Relevant dental /medical history Clinical evaluation of dental trauma -Rule out presence of other injuries i.e. head and neck injuries -Examine for presence of soft tissue lacerations, bone fractures Investigations -Dental periapical radiograph for baseline records .
- 17. Replantation Place the toothin physiological saline Administer local anesthesia Gently irrigate socket with normal saline Avoid scraping or curettage within the socket Handle the tooth by its crown only If the root is contaminated, run physiological saline over the tooth. If dirt is stubborn, gently dab with gauze soaked in saline Seat the tooth back gently into its socket using light finger pressure Instruct child to bite on a piece of gauze If socket walls are fractured, and unable to replant tooth, reposition bone gently using blunt instrument
- 18. Splinting •Splint teeth toadjacent teeth using physiological splinting method. Types of splints: - Direct composite splint (Fig. 3) - Wire composite splint (Fig. 4) - Fibre reinforced meshed splint . •Splint teeth for 7 – 14 days. If alveolar bone is fractured, splint for 4 weeks. •Take a periapical dental radiograph to ascertain position of replanted tooth and as baseline information. •Give home care advice during splinting such as: - Avoid biting on splinted teeth - Take soft diet - Maintain good oral hygiene Figure 3: Direct composite splint Figure 4: Wire composite splint
- 19. - Oral antibiotics,preferably penicillin based for 5 days - Oral analgesic (if patient is in pain, simple oral painkillers such as Syrup Paracetamol 10-15mg/kg stat may be given) - 0.12% chlorhexidine gluconate mouthwash twice daily for 1 week .
- 20. 11 5.4 FOLLOW UP Successrates for survival of avulsed teeth also depend on the management of the replanted tooth during follow- up visits. 13,14,level III, 28,29,level I, 30-33,level III 5.4.1 Tooth with Closed Apex 1,2 level I Duration Recommended Procedures One Week i. Check for clinical signs and symptoms of infection* ii. Commence root canal treatment - Extirpate pulp - Carry out mechanical preparation of canal - Dress canal with calcium hydroxide paste iii. Seal access cavity with suitable intermediate restorative materials such as Glass Ionomer Cement (GIC) iv. Take radiograph to check for adequacy of fill v. Remove splint if tooth is fairly firm. If not, review weekly until firm One Month i. Check for clinical signs and symptoms of infection* ii. Take periapical dental radiographs iii. If no signs and symptoms, obturate the root canal followed by tooth restoration iv. If signs and symptoms of infection persist, change calcium hydroxide dressing Three Months i. Check for clinical signs and symptoms of infection* ii. Take periapical dental radiographs iii. In unobturated root canal, change calcium hydroxide dressing three monthly until signs and symptoms of infection has cleared. Once infection has cleared, proceed to obturate canal iv. Regular review 6 monthly for 2 years
- 21. 12 5.4.2 Tooth withOpen Apex 1,2 level I Duration Recommended Procedures One week i. Check for clinical signs and symptoms of infection.* ii. Check for pulp vitality iii. When signs and symptoms of non-vital pulp arise, dress with calcium hydroxide to control the infection then institute apexification procedures iv. Remove splint if tooth is fairly firm. If not, review weekly until firm Monthly for three months i. If previously tooth vital: - Check for clinical signs and symptoms of infection* - Check for pulp vitality. - Take periapical dental radiographs. - When signs and symptoms non-vital pulp arise, dress with calcium hydroxide to control the infection then institute apexification procedures ii. If infection has been controlled, institute apexification - Change calcium hydroxide or - Use MTA for one visit apexification, then obturate canal34,level III Three monthly for 6 months or more i. If previously tooth vital: - Check for clinical signs and symptoms of infection* - Check for pulp vitality - Take periapical dental radiographs. - When signs and symptoms of non-vital pulp arise, dress with calcium hydroxide to control the infection then institute apexification procedures ii. If apexification has been instituted - Check signs and symptoms of infection* - Take periapical dental radiographs - Change calcium hydroxide if necessary every three monthly until calcified barrier formation is achieved, then obturate canal Six Monthly i. If previously tooth vital - Check for clinical signs and symptoms of infection* - Check for pulp vitality - Take periapical dental radiographs - When signs and symptoms of non-vital pulp arise, dress with calcium hydroxide to control the infection then institute apexification procedures ii. If apexification has been instituted - Check for signs and symptoms of infection* - Take periapical dental radiographs * Clinical signs and symptoms include: i. pain/ tenderness ii. swelling/ sinus iii. mobility iv. tooth discolouration v. pathological radiolucency at the periapical area
- 22. xii Root Apex Status Avulsedtooth ALGORITHM FOR THE MANAGEMENT OF AVULSED PERMANENT ANTERIOR TEETH IN CHILDREN i) Flexible splint for a week ii) Baseline radiograph iii) Home careadvice iv) Medications – antibiotics, analgesic & mouthwash Follow up 1 week i) Check signs/symptoms* ii) Commence RCT iii)Dress canal with Ca(OH)2 iv) Remove splint if tooth firm Follow up 1 week i) Check signs/symptoms* ii) Check pulp vitality iii) Remove splint if tooth firm Follow up 1 month i) Check signs/symptoms* ii) Change Ca(OH)2 if required iii) Obturate root canal Follow up 3 months i) Check signs/symptoms ii) Review 6 monthly till 2 yrs Follow up 1 month i) Check signs/ symptoms* ii) Take periapical radiograph Follow up 3 months i) Check signs/ symptoms ii) To take periapical radiograph iii) Start RCT if signs/symptoms arise Immediate replantation not possible Store in appropriate storage medium (milk/saline/saliva) Immediate replantation on the spot Open (> 1mm) Closed Vital Non-Vital Apexification At the site of injury At the dental clinic Follow up Replant Tooth ? Repla ce with space maintainer/close space orthodontically Replant Tooth? Multi-visits i.Dress canal with Ca(OH)2 ii.Change Ca(OH)2 every 3 monthly until formation of calcified barrier iii) Obturate canal One-visit i) Placement of MTA as an apical plug Ii) Followed by canal obturation RCT – Root Canal Treatment MTA – Mineral TrioxideAggregate No Yes
- 23. The objective ofapexification is to achieve formation of a calcified apical barrier, which facilitates effective root filling. This may be assessed radiographically or clinically at each review visit. If calcium hydroxide change is necessary, use Glass Ionomer Cement (GIC) to seal access cavity in between visits. Once apical closure is achieved, seal canal with gutta percha and restore access cavity. After completion of root canal treatment the tooth should be reviewed yearly for two years to ensure that no signs or symptoms of infection are present.33,level III
- 24. 5.5 PROGNOSTIC FACTORS Theoutcome of treatment depends on the physiological condition of the periodontal ligament cells and pulp tissue at the time of replantation. Immediate replantation gives better prognosis. Immediate referrals/consultation to a Paediatric Dental Specialist is highly recommended.