Delayed Replantation of an avulsed permanent tooth in a young
patient-Does Silver Diammine Fluoride surface treatment has a role?
Running Title-Role of SDF in avulsed permanent tooth
Abstract
Dental trauma in children are common occurences.Avulsion of anterior
teeth due to trauma is seen in both primary and young permanent
teeth.The standard protol for avulsion in permanent teeth is immediate
replantation but many a times its not possible.Delayed replantation of
avulsed permanent teeth has a poor prognosis still it is worth a try to
replant an avulsed tooth for the completion of facial growth and to
prevent the psychological impact the loss of anterior teeth can have on
a young child.Here we discuss a case of replantation of Maxillary
anterior teeth in a seven years old male child who reported sixteen
hours after the trauma.This is probably the first case in literature
where application of Silver Diammine Fluoride(SDF)on root surface to
prevent resorption was done,which is the main reason of failure of teeth
with delayed replantation.
Keywords-Avulsed teeth,Replantation,Silver Diammine Fluoride,Trauma
Introduction
Complete displacement of tooth from the socket is termed as avulsion.The
prevalence of avulsed permanent teeth is
0.5%-18.3%.1The prevalence of avulsion increases in
the age range of 7-9 years due to incomplete root development and
minimal resistance of the alveolar bone/periodontal ligament (PDL)
against extrusive forces during the eruption period of the teeth.The
etiology of tooth avulsion varies in accordance with the type of
dentition.In deciduous dentition avulsions are usually caused by hard
objects hitting the teeth,whereas in permanent teeth avulsions are due
to falls,fights,sportsinjuries,accidents and child
abuse.2In both the primary and permanent dentition
,maxillary central incisors are the teeth mostly
avulsed.3Incompetent lips and increased overjet are
added predisposing factors for avulsion
injuries.4Tooth avulsion can lead to damage to pulp
and periodontal ligament,which leads to post traumatic
complications.Tooth avulsions may also cause injury to supporting tooth
structure,lips and might lead to multiple avulsions.5
The standard protocol for treatment of an avulsed permanent tooth is to
preserve and treat the supporting tissues and replant the avulsed
tooth/teeth.Many factors delineate the success of a replanted
tooth-extra-oral dry time,storagemedium,patients general health and
maturity of root of the tooth.6The period of
extra-oral time and storage medium are the most critical components for
the success of a replanted tooth.7Here we discuss a
case of delayed replantation of maxillary central incisors in a seven
years old male child with root surface treatment with Silver Diammine
Fluoride(SDF).
Case Report
A seven-years-old male child reported to the dental clinic with a chief
complain of avulsed permanent teeth(Fig 1,2).The child had a trauma 15
hours back while playing with his friends in school. The child had
visited a physician who administered tetanus toxoid and also put sutures
for extra-oral laceration wound in mandible.There was no history of loss
of consciousness or vomiting or any systemic disease. The parents had
got the avulsed maxillary central incisors(11,21)in milk as storage
media(Fig 3).The child being young we considered replantation of the
teeth as the facial growth was not completed and both the child and
parents were concerned regarding the esthetics of the child.The complete
treatment plan was explained to the parents along with prognosis and
written consent was taken.The parents were also explained about the poor
prognosis of the teeth because of the increased extra-oral time.
Intra-oral periapical radiograph did not reveal any broken fragments of
alveolar bone or tooth(Fig 4).The sockets were cleaned with normal
saline and Betadine(Win-Medicare Pvt.Ltd,NewDelhi,India) and the root
surfaces were debrided too.This was a delayed replantation of more than
60 minutes,so it was decided to perform the endodontic therapy
extra-orally(Fig 5).Access was made,pulp was removed and canals
irrigated with 5.25% sodium hypochlorite and 2%
chlorhexidine.Biomechanical preparation was done till size F3 Protaper
(Denstply Sirona,Canada)file.Tooth 11 was obturated with F3 Gutta Percha
along with AH plus (Dentsply Sirona,Canada) after root end closure with
amalgam whereas 21 was obturated with MTA(Dentsply Sirona,Canada).The
canals were closed with Glass ionomer cement as interim restoration.The
roots of both teeth were debribed and cleaned with pumice.The root of 11
was treated with Fluoride varnish(Fluoritop,ICPA Health,India) and 21
was treated with SDF(Fagamin,Tedequim,Argentina)(Fig 6,7).The sockets
were curetted thourougly and blood clot was removed.Bleeding was
controlled.The teeth 11 and 21 were placed inside the sockets gently
with finger pressure after application of local anaesthesia(Fig 8).The
teeth were splinted with soft orthodontic wires from first deciduos
molar to first deciduous molar on both sides.i.e 54 to 64(Fig
9).Intra-oral periapical radiograph was taken to check the placement of
replanted teeth in socket(Fig 10).The patient was prescribed antibiotics
and analgesics for 7 days and sent with oral hygiene instructions.The
patient was advised for soft diet for 7 days.The patient was recalled
after 4 weeks for splint removal.Periapical radiograph was taken for
checking the resorption,if any.During this period,the pandemic
started(COVID-19)and the patient did not come up for follow up.We only
monitored the case through video conferencing without any
radiographs.After 26 months,with little decline in cases of COVID-19 and
after much persuasion the parents agreed to come for follow up of the
child.On clinical examination,11 was showing pink discoloration on
cervical region and OPG also confirmed resortion of root(Fig 11).21 was
both clinically and radiographically sound.The case is being followed up
still and the parents have been told about the prognosis of 11.
Discussion
The complete displacement of tooth from its socket occurs when the tooth
directly sustains a force.In both primary and permanent
dentitions,maxillary central incisors are commonly avulsed because of
their prominence in jaw.8The guidelines of treatment
of avulsed teeth may vary but the wide consensus is to replant the tooth
as soon as possible.But sometimes it is not possible.The treatment
depends on the root maturity of the avulsed tooth(Open /Closed apex) and
the PDL cell viability.9The PDL cells viability is
dependent on the extra-oral time and the storage medium.The extra-oral
time defines the prognosis of the replanted teeth.Clinical studies have
elaborated that the prognosis is best for replantation of teeth within 5
minutes.The extra-oral time of more than 60 minutes will lead to loss of
PDL cell viability.10The storage and transport medium
during the extra-oral time also serves to decide the prognosis.In those
patients with more extra-oral time of avulsed tooth the,tooth should be
stored in suitable medium like HBSS solution,milk,saliva ,coconut water
and if nothing available then water till he/she gets to a
dentist.11 There have been reports of replanted teeth
remaining in function for over 30 years. On an average, they are
functional at least for 5 years and most are ultimately lost because of
progressive root resorption or other associated problems like
ankylosis.12
In the presented case,the extar-oral time was more than 15 hours but
teeth were bought in milk as storage medium.The replantation was done in
accordance to International Association of Dental Traumatology( IADT
)guidelines.13The extra-oral time was more than 60
minutes,so the endodontic treatment was done extra-oral prior to
replantation.As the PDL cells and the pulp will not be
viable,revascularisation can not be attempted.The long term prognosis of
teeth with delayed replantation is poor,because of non viability of PDL
cells.Most of the avulsion injuries occur before the facial growth is
completed.14Ideal requisite is to prevent the
resorption of bone till facial growth is completed.Replantation also
prevents the psychological trauma associated with the facial appearance
and esthetics.The facial esthetics was the major concern of the parents
and the child in our case.The replantation is to be done till the child
can be ready for a more permanent treatment option like fixed prosthesis
or implant.If replantation can not be done we can manage the case with
orthodontic space closure,auto transplantation of another
tooth.15 The avulsed tooth should be stored in storage
media until replanted. Further, conditioning the root surface of the
tooth with the appropriate agent can increase the chances of functional
healing. PDL vitality is the primary factor in the prevention of
ankylosis in cases of dental avulsion. A variety of adjunctive
treatments have been proposed to prevent and delay root resorption
before replantation thereby increasing the survival of replanted
teeth.Various materials like sodium fluoride,triple antibiotic
paste,Enamel Matrix Derivative(EMD),Fibroblast growth Factor(FGF) have
been used for root surface treatment.16,17,18,19But
till now not a single case report has attempted SDF for root surfcae
treatment.We utilised SDF and have got good results till 26 months.More
cases have to be done to come to a conclusion on the role of SDF as
surface treatment agent for root in avulsed teeth.
Conclusion
Replantation of avulsed tooth has to be done even in case of prolonged
extra-oral time.The parents have to be explained about the prognosis.In
young patients in whom the growth has not ceased the replanted teeth
will help to prevent bone resorption and also prevent the psychological
impact on the child.Here we discussed the use of SDF for root treatment
which is probably the first time followed for 26 months without
resorption.Although it might be early to judge the success,still SDF can
be tried in avulsed tooth for root treatment.
Why this paper is important to paediatric dentists
- Surface treatment of root is essential for any delayed replantation
case.Many products have been used but this is the first case to
utilise SDF and got good results
- The pediatric dentists must try to replant the avulsed teeth as soon
as possible which if not possible can be delayed and replanted
- Use of storage media is important when transporting the avulsed teeth.
Conflict of interest-Nil
The Author has done the case,searched the databases and written the
manuscript.
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