DENTAL CARE FOR CHILDREN AFTER REPLANTATION OF AVULSED PERMANENT INCISORS
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https://doi.org/10.5272/jimab.2016224.1392
Journal of IMAB
Journal of IMAB - Annual Proceeding (Scientific Papers) 2016, vol. 22, issue 4
ISSN: 1312-773X
http://www.journal-imab-bg.org
DENTAL CARE FOR CHILDREN AFTER
REPLANTATION OF AVULSED PERMANENT
INCISORS
Rossitza Kabaktchieva1, Natalia Gateva1, Angela Gusiyska2, Pavel Stanimirov3, Nina
Milcheva4
1) Department of pediatric dentistry, Faculty of Dental medicine, Medical
University- Sofia, Bulgaria
2) Department of Conservative Dentistry, Faculty of Dental medicine, Medical
University- Sofia, Bulgaria
3) Department of Oral and Maxillo-Facial Surgery, Faculty of Dental medicine,
Medical University- Sofia, Bulgaria
4) Department of pediatric dentistry, Faculty of Dental medicine, Medical
University-Varna, Bulgaria
SUMMARY: (forth case) healing process is stable and the prognosis is
The diagnosis avulsion of permanent tooth/teeth is good. Follow up period for all the replanted teeth has con-
an emergency situation which has special requirements in tinued.
respect of proper storage of the avulsed tooth, the need of Conclusion: The presented clinical cases show that
urgent medical/dental care, time past till replantation and there is a lack of dental teams for complex treatment of chil-
splinting, the need for endodontic treatment and long term dren with avulsed teeth in Bulgaria. Dental specialists have
follow up period. Those clinical actions depend on three no good information about recommended by IADT
groups: parents/people who are with the child in the mo- protocols (www.iadt-dentaltrauma.org), for the treatment of
ment when trauma happens and give the first aid; dental teeth undergoes avulsion during childhood. Parents of these
specialist- surgeon who replants the tooth/teeth; dental children have no proper information about how to store the
specialist- endodontist who takes care of the endodontic teeth which are avulsed and found immediately after
treatment and the long period after treatment for follow up trauma.
and observation of the replanted teeth.
The aim of the paper is to present the dental post- Keywords: dental trauma, dental avulsion, replan-
operative care in a couple of cases of children with trauma tation, permanent teeth,
and replanted avulsed permanent incisors.
Material and methods: We present four clinical Àvulsion is one of the most serious dental injuries [1-
cases of children who get 6 permanent upper incisors re- 6]. Prognosis for the replanted permanent teeth in children
planted. Replantation is made by the oral surgeon. Treat- is hard and the åxtraoral storage of the avulsed tooth [7],
ment and observation after replantation are made by den- time past from the moment of trauma till that of replanta-
tal specialists of pediatric dentistry and conservative den- tion of the avulsed tooth [8], the stage of root development
tistry. All 4 cases get 3 years follow up period. [9, 10]and protocol for replantation [2, 3] are important for
Results: After replantation of 2 central incisors with it. The aim of replantation is to restore the aesthetics, func-
complete root development (first clinical case) the left one tion and to maintain the alveolar bone contour [1, 2, 11-
has developed a resorption of the root but the right one is 13]. Prognosis for replantation of permanent teeth which stay
in a stable condition. Replantation of 3 teeth with incom- out of the mouth less than 60 minutes after an accident is
plete root development (second and third clinical cases) good and expected ankylosis lead to slow root resorption
where the patients refer to specialized surgical care less after a couple of years [2, 3, 14, 15]. Revascularization of
than 60 minutes after injury and store the teeth in differ- the replanted teeth with immature root development is a re-
ent ways lead to different clinical results. In the case of markable outcome [9, 16]. Replantation after more than 60
avulsed upper right incisor (second case), it is stored in minutes after the accident (delayed replantation) has a poor
milk and we observe revascularization followed by partial long-term prognosis. The periodontal ligament will be
root canal obliteration. The tooth is scheduled for endo- necrotic and not expected to heal. The goal in delayed re-
dontic treatment. In the case of upper central incisors, both plantation is, in addition, to restoring the tooth for esthetic,
kept dry till replantation in the alveolus filled up with sub- functional and psychological reasons and to maintain alveo-
stitute bone, we observe fast root resorption which going lar bone contour [2, 3, 17, 18]. However, the expected out-
to lead to early tooth loss. After replantation of the first come is ankylosis, root resorption, and eventual tooth loss
upper incisor with open apex, stored in physiological so- [2, 3, 19, 20]. In the last few years, dental practitioners re-
lution for 5 hours and with delayed endodontic treatment port for coronal removal of replanted teeth and successful
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preservation of the alveolar contour [21, 22, 23]. All efforts lowed up for 3 years. The method of case‘s presentation is
about the long term complicated treatment are made for the descriptive, illustrated with pictures and X-rays, which give
preservation of the alveolar bone [1, 2, 3]. a short information about the treatment in the emergency
There are three important aspects in a discussion situation and later in the period of postoperative care.
about traumatic injuries like avulsion: information for first
aid and proper storage of the avulsed tooth [24 - 30], mod- First clinical case
ernization of the replantation protocol [12, 31-34]and the A. I., 11 years old girl. She had syncope and hit her
professional medical and dental care for the replanted face on the floor and as a result avulsed her upper incisors.
tooth[12, 35- 40]. She was taken to the hospital and after EEG and detailed
The aim of the article is to present dental postop- medical check - up she was scheduled for replantation of
erative care for children with replanted avulsed permanent the avulsed teeth under general anesthesia. The teeth
incisors. stayed out of the mouth for about 1 hour and were stored
dry. The injured teeth were with completed root develop-
MATERIAL AND METHODS: ment. There was no information about the protocol of re-
We present four clinical cases of children with re- plantation of the incisors in the hospital. The teeth were
planted six permanent upper incisors. Protocols for replan- immobilized by a rigid metal splint (fig. 1-A, B). Tooth 11
tation are performed by oral surgeons. Pediatric dentists and was replanted in infra occlusion compared to tooth 21 ac-
endodontists take the postoperative dental care and con- cording to an old radiograph (fig. 1-C). Antibiotics were
trol the follow up period. Presented clinical cases are fol- prescribed to the patients.
Fig. 1. A.I.,11 years old girl. A) OPG after replantation and splinting of teeth 11, 21. B) there is a disparity in the
level of incisor‘s cut edges between replanted teeth. C) OPG before the injury.
The splint had been taken down after 2 weeks. The The extraoral appearance of the replanted teeth
patient was referred to a general practitioner for continu- shows the disparity in the level of incisor‘s cut edges (fig.2-
ing treatment and control. Four months later her dentists B). The patient had no complaints but was informed about
hadn‘t done any endodontic treatment to the replanted the root resorption. The patient was ready to cooperate in
teeth. Four and a half months later another radiograph was the following treatment.
taken and started root resorption of tooth 21 was observed After clinical examination, no any pathological mo-
(fig. 2-A). The patient was referred to a pediatric dental spe- bility, tenderness to percussion or palpation were registered.
cialist. Teeth were stable. Electric pulp test (EPT) of the both teeth
showed rates over 200µA. Our treatment plan had included
Fig. 2. A) X-ray four and a half months after replan- immediate root canal treatment to teeth 11 and 21 by fol-
tation. Root canal treatment hadn’t been done before. Peri- lowing a treatment protocol for teeth with complete root
apical inflammation and root resorption had been observed development: extirpation of the necrotic pulp (fig. 3-A);
to tooth 21. B) Picture of the replanted central upper inci- mechanical and chemical treatment of the root canals and
sors four and a half months after the accident. application of Calcium hydroxide (Metapex - Calcium hy-
droxide with iodoform, META BIOMED) for a month (fig.3-
B).
Control visit and radiograph were taken 1 month
later. The patient had no complaints and any clinical symp-
toms. The radiograph showed that there was a root
resorption progression which reached the root canal fill-
ing (fig.3-B).
It was made a 3D-radiograph, which confirmed root
resorption and partial osteolysis (fig.3-D).
/ J of IMAB. 2016, vol. 22, issue 4/ http://www.journal-imab-bg.org 1393
Fig. 3. A) Extirpation of the pulp at the stage of necrobiosis of teeth 11, 21. B) X-ray of teeth 11, 21 –root canals
were filled up with Metapex. C) X-ray 1 month later- root resorption of tooth 21 was progressing and reached part of the
root canal filling D) 3D radiograph showed the area of osteolysis.
Despite the progressing resorption after consultation radiographic pathology, there was no progression of the
with a radiologist and endodontist the endodontic treat- root resorption of tooth 21 (fig. 4-B).
ment was continued. The root canals were filled with Next control check-up and radiograph were made 23
bioceramic sealer Root SP (Innovative BioCeramix, months after replantation. There was no tenderness to per-
Canada) and Gutta-percha (fig.4-A). The permanent filling cussion and palpation. It was observed inner root resorption
was made with Filtek™ Supreme Ultra, 3M ESPE Dental. in the cervical region of tooth 21. Root resorption in the
Control check-up and radiograph 12 months after endodon- apical region was stable and there was no progression. There
tic treatment and 17 months after replantation registered: were no any radiographic pathological changes seen on
the patient had no clinical symptoms, tooth 11 had no any tooth 11. Follow up period was continued.
Fig. 4. A) The root canals were filled with iRoot SP® and Gutta-percha. B) Control radiograph 1 year after endo-
dontic treatment. There were no newly formed resorption lesions. C) Control radiograph 1 year and a half after the
endodontic treatment. Apical region of tooth 21 was stable but new inner resorption was observed in the cervical area.
Second clinical case to a pediatric dentist and the instructions were to keep the
M. A. 8 years old boy, who during trampoline game tooth in the alveolus by biting gauze between teeth.
hit himself and avulsed tooth 11. The tooth was found and In the pediatric dental office, the injured tooth was
the father called the clinic to get instructions in that emer- splinted to the neighbor healthy teeth by a flexible splint
gency situation. The tooth was washed carefully and trans- (Kevlar fiber) and composite for 2 weeks (fig. 5-A). A radio-
ported in milk. The period from the accident till replanta- graph has been taken and it showed intrusion of the tooth
tion of the tooth was less than 60 minutes. The tooth was 12 (fig. 5-B). The systemic antibiotic has been prescribed
with incomplete root development (open apex). (Augmentin 250mg) and control visit was scheduled. Instruc-
The child was taken to the clinic of maxillofacial tions to the patient included not to bite with the injured
surgery where the tooth was replanted. The wound was ir- tooth, soft by consistence food, adequate oral hygiene with
rigated with blood coagulum. The surgeon replaced the tooth paste and soft tooth brush after every meal and under
tooth with light pressure in the alveolus. Radiographs had parents control, 2 times a day for 1 week the patient should
not been taken before or after the replantation. The tooth rinse the mouth with chlorhexidine (0.1 % mouth wash); the
had not been splinted. The patient was immediately sent child should be taken to the clinic if any symptoms occur.
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Fig. 5. M.A. 8 years old boy. A) Tooth 11 right after Chance for revascularization of the pulp of the in-
replantation and splinting. Lateral right incisor couldn‘t be jured tooth was included in the treatment plan. If
seen in the mouth. The gingiva was bleeding and there was revascularization hasn‘t become evident an endodontic
edema. There were no lacerations. B) X-ray right after the treatment would be done. The prognosis for the intruded
replantation and splinting of tooth 11. It was registered full tooth was that it will reerupt again and will take its place
intrusion of the upper right lateral incisor. in the dental arch.
Follow up- visual and radiographic criteria:
Two weeks after marginal gingiva was healthy, pink
and did not bleed. The replanted tooth was with no
discolorations and symmetrical compared to tooth 21 (fig.6-
A). One month later the marginal gingiva was healthy. The
replanted tooth had no discolorations. The splint would be
taken down (fig.6-B). Replanted tooth showed signs of an-
kylosis and no resorption (fig.6-C). Three months after the
accident the marginal gingiva and the interdental papilla
were healthy and embedded the tooth tightly. Tooth 11 had
no discolorations and hadn‘t changed its location (fig.6-D).
Fig. 6. M.A. 8 years old boy. A) Clinical appearance 2 weeks after the accident. Marginal gingiva looked healthy
and did not bleed. Replanted tooth hadn‘t been discolored and was symmetrical compared to tooth 21. Tooth 12
reerupted. B) Clinical appearance 1 month after the replantation. The marginal gingiva was pink and healthy. The
replanted tooth had no discoloration and tooth 12 fully reerupted. C) X-ray- replanted tooth showed signs of ankylo-
sis and no root resorption. D) Clinical appearance 3 months after the accident. Marginal gingiva and interdental pa-
pilla were healthy and embedded the tooth tightly. Tooth 11 had no discolorations and had no change in its location.
Seven months later the marginal gingiva was gression (fig. 7-D). 2 years after the treatment the replanted
healthy, the replanted tooth had no pathological changes tooth had no discolorations. A slight rotation of its mesial
(fig.7-A). The injured tooth was asymptomatic. There was edge could be observed (fig. 7-E). The tooth 11 was asymp-
a tendency for the obliteration of the root canal and slight tomatic, with obliteration of the root canal and evident api-
root resorption in the apical region (fig. 7-B). One year af- cal resorption (fig.7-F). Three years after the accident re-
ter the accident the replanted tooth was completely sym- planted tooth was with no discolorations and was asymp-
metrical to tooth 21 (fig. 7-C). Tooth 11 was asymptomatic tomatic (fig. 7-G). The tooth was asymptomatic, with evi-
but the root canal obliteration and resorption had a pro- dent root canal obliteration and apical resorption (fig.7-H).
Fig. 7. A) Clinical appearance seven months after the accident. B) X-ray- the tooth was asymptomatic. The tendency
to the obliteration of the root canal and slight signs of apical resorption. C) M.A. 9 years old–clinical appearance 12
months later. Replanted tooth was fully symmetrical compared to tooth 11 D) X-ray showed a tendency to the obliteration
of the root canal and advanced apical resorption. E) M.A. 10 years old. Clinical appearance 2 years later. Replanted tooth
had no discolorations. There was a slight rotation of the mesial edge. F) X-ray showed obliteration of the root canal and
apical root resorption G) M.A. 11 years old. Clinical appearance 3 years after the replantation. Replanted tooth was with
no discolorations and was asymptomatic. H) X-ray showed root canal obliteration and developed apical resorption.
/ J of IMAB. 2016, vol. 22, issue 4/ http://www.journal-imab-bg.org 1395
Mobility test: Tooth is stable after taking down the noninvasive method to determine and monitor oxygen satu-
splint (4 weeks after the accident). The mobility was con- ration of the pulp. The method shows the percentage of
trolled after 3 months, seven months after the treatment saturated with oxygen hemoglobin in the blood. Rates be-
and once a year every year till the third year after the acci- tween 95%-100% are the referent. Rates under 92% show
dent. The tooth was absolutely stable. hypoxia or lower level of oxygen in the blood. The method
Percussion test: Replanted tooth didn‘t show any is a part of the complex assessment of the tooth condition
tenderness to percussion 1 week, one month, three months, same when it is stable and during the period of exacerba-
seven months, 1 year, 2 years and 3 years after treatment. tion (fig.8).
The percussion tone was “deaf”. Patient results: 10 years old - tooth 11 = 76 % O2
Electric pulp test (EPT): One week, one month, 3 saturation, tooth 21 = 78% O2 saturation
months, seven months, one year, two years and 3 years af- 11 years old – tooth 11 = 80% O2 saturation, tooth 21=
ter replantation test showed referent rates. 95% O 2 saturation
Test of pulse oximetry: Pulse oximetry is a
Fig. 8. A) Pulse oximetry appliance. B) M.A. 10 years old boy – pulse oximetry testing on teeth 11 and 21.
Third clinical case
M.V. 8 years old boy who had fallen on training and Biomaterials) and the teeth were replanted with light pres-
avulsed his upper right and left central incisors. Teeth were sure and no splinting. OPG was taken for control of replan-
found and the child was taken to an oral surgeon who de- tation (fig. 9-A). Systematic antibiotics were prescribed.
cided that there were conditions for replantation of the The patient was not consulted for tetanus prophylaxis. It
teeth. The diagnosis was Expulsio dentis of teeth 11, was given an instruction for home care in the postopera-
21with incomplete root development. Teeth stayed out of tive period. During next two months, replanted teeth were
the mouth less than 60 minutes and were transported dry, controlled by the oral surgeon. Visually tooth 11 was in
in a box. The aim of replantation was revascularization of infra position compared to tooth 21 but over the marginal
the dental pulp. Root canal treatment would be conducted gingiva, it was observed sinus tract (fig. 9-B). On a control
if there are evidence for pulp necrosis, clinical and radio- radiograph an advanced root resorption on tooth 11 was
graphic. registered (fig.9-C). The tooth was movable. The patient
Protocol for replantation included cleaning the teeth had no any complaints but has noticed the inflamed
and alveolus with physiological solution, filling up the al- gingiva. The patient was referred to a pediatric dentist for
veolus with Bio-Oss® spongiosa 0,25-1mm (Geistlich subsequent treatment.
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Fig. 9. M.V. 8 years old boy. A) OPG after the replantation of teeth 11 and 21. B) Intraoral appearance 2 months
after replantation. The gingival margin on the vestibular side of tooth 11 was way above the enamel-cementum junc-
tion, there was sinus tract and the tooth was with pathological mobility. The cut edge of tooth 11 was in infra position
compared to that of tooth 21. Slight discoloration of tooth 21 was observed. C) X-ray two months after replantation
showed resorption ankylosis on tooth 21 (diagnosed by Assoc. Prof. P. Stanimirov). Tooth 21 had no pathological changes
up to radiograph criteria.
Treatment and follow up made by pediatric dentist paste Metapex has been resorbed to the middle of the root
The pathological mobility of tooth 11 was a reason canal of tooth 21 (fig.10-D). Nine months later sinus tract
for the decision to apply a flexible splint (Kevlar fiber), appeared again on the gingiva above tooth 11(fig.10-E).
which was fixed to the neighbor teeth with composite resin The radiograph showed that Ìetapex in the root canal of
(fig. 10-A). EPT revealed pulp necrosis on tooth 21 (>200 tooth 21 has been resorbed again partially (fig.10-F). Root
µA). Root canal treatment was immediately scheduled for canal treatment of tooth 11 had started. The root canal was
tooth 21 which included irrigation with NaOCl and appli- filled up with Metapex in order to treat local inflamma-
cation of calcium hydroxide paste (Metapex/META tion. Parents refused control radiograph on tooth 11 after
BIOMED, Calcium hydroxide with iodoform) (fig.10-B). the beginning of endodontic treatment. Twelve months
Tooth 11 was put under observation because of a minimal later patient didn‘t show up for control check-up and the
chance for adequate endodontic treatment. contacts were discontinued. Two and a half years after the
Control check-ups: six months after treatment pa- accident patient came again for control visit. Replanted
tients had no complaints. After splinting the sinus tract teeth were asymptomatic. Part of the splint was still on the
above the gingival margin of tooth 11 healed with no other teeth (fig.10-G). The splint was removed (fig.10-H). There
treatment. Tooth 21 was asymptomatic. The eruption of was supra gingival calculus on the lower front teeth. Pro-
tooth 22 made the repair of the splint necessary (fig.10-C). fessional dental hygiene was made. A radiograph revealed
Control radiograph showed that the calcium hydroxide advanced root resorption to both teeth (fig.10-I).
Decision for subsequent regular check-ups and observation has been taken
Fig. 10. A) Teeth were splinted two months after replantation to improve the stability of tooth 11. B) The root
canal treatment was performed according to the protocol for treatment of periodontitis of teeth with incomplete root
development. The root canal of tooth 21 was obturated temporary with Metapex. C) Six months later sinus tract hadn‘t
been observed on tooth 11; tooth 21 was asymptomatic; the splint was repaired because of the eruption of tooth 22. D)
The radiograph showed that Metapex paste was resorbed to the middle of the root canal. E) Nine months later sinus
tract appeared again in the same location above tooth 11. F) The radiograph showed partial resorption of Ìetapex paste
in the root canal of tooth 21. G) M.V., ten and a half years old. Two and a half years after the accident part of the splint
was still bonded on the vestibular surfaces of the front upper teeth. Teeth were relatively stable. The presence of supra
gingival calculus pointed the fact that the child hasn‘t bite. H) Replanted teeth after removal of the splint parts. I) A
radiograph revealed advanced root resorption of both teeth and residual calcium hydroxide paste.
/ J of IMAB. 2016, vol. 22, issue 4/ http://www.journal-imab-bg.org 1397
Forth clinical case
N.R, 9 years old girl who was referred to us for con- Fig. 11. A) X-ray 11 months after replantation of
sultation and treatment of upper left central incisor. The tooth 21 with which the child came to the specialist. The
patient underwent trauma, avulsio dentis, 11 months ago. diffuse periapical lesion was observed. B) Tooth 21 with
The tooth was replanted after 5 hours being out of the calcium hydroxide paste applied in the canal. C) X-ray of
mouth by a surgeon in an emergency room. The tooth was tooth 21 for determination of working length of the root
splinted to the neighbor teeth for 10 days. No plan for fol- canal, gutta-percha point was used. D) Control X-ray after
lowing treatment and control was made. During that period, the permanent restoration of the root canal of tooth 21. E)
no EOD or control radiograph was made to observe the con- Control X-ray 18 months after endodontic treatment. The
dition of the tooth. The tooth stayed intact for 10 months. periodontal gap is normal through the whole root length.
The acute periapical abscess was the reason for opening There were no signs of resorption.
the pulp camber and evacuating the purulent exudate. An-
tibiotics (Ospamox) were prescribed and the patient was re-
ferred to a specialist for further endodontic treatment. On
a control radiograph, which the patient brought to the en-
dodontist it was observed an opened pulp chamber and dif-
fuse periapical lesion (fig. 11-A). Ten days after the acute
period the tooth had slight tenderness to palpation and pain
from vertical percussion was registered. There still has been
observed purulent exudate in the canal. Endodontic treat-
ment had been done by following the protocol for treat-
ment of exacerbated periodontitis of tooth with incomplete
root development. After mechanical and chemical root ca-
nal treatment, a calcium hydroxide paste was applied for
10 days (fig.11-B). There were some difficulties to deter-
minate the actual root canal length and a control radiograph
with gutta point No 80 had been made (fig.11-C). After the
root canal working length was determinate it was obdurate
permanently with bioceramic sealer (TotalFill, FKG, Swit-
zerland) and gutta-percha (fig.11-D).
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Regular control check-ups were scheduled. The tooth resorption is registered. There are no complaints or patho-
had no tenderness to palpation and percussion after the per- logical changes of tooth 11 during the whole follow up pe-
manent restoration of the root canal. Control X-ray 18 riod of two years. The clinical case has a good prognosis
months after endodontic treatment (and 27 months after re- about the level of front alveolar bone. The monitoring of
plantation) revealed satisfactory results, the normal condi- the clinical case continues.
tion of the periodontal tissues and periodontal gap (fig.11- We support the opinion of the most researchers who
E). There were no signs of resorption ankylosis. state that avulsed teeth should better be replanted. The
long-term prognosis is that they will be lost because of pro-
DISCUSSION gressive resorption. The good result of replantation any
According to contemporary classifications and way is that it will preserve the level of alveolar bone. In
guidelines [2, 3, 4] for the treatment of dental traumas, our the mix dentition, replanted teeth preserve from vertical
first clinical case is about avulsion and replantation of per- and horizontal loss of a bone and favor future orthodontic
manent teeth with complete root development which treatment or placement of a tooth implant.
stayed out of the mouth for more than 60 minutes. That The second clinical case presents replantation of
means that neuro-vascular trunk and periodontal fibers are avulsed tooth with incomplete root development, which
torn and the root surfaces of the avulsed teeth are exposed. stayed out of the mouth less than 60 minutes and has been
The protocol for treatment of replanted permanent teeth stored properly. The goal for replanting still-developing
with complete root development according to IADT [3] re- (immature) teeth in children is to allow for possible
quires: storage of the avulsed tooth should be in a physi- revascularization of the pulp space [2, 3]. The protocol for
ological solution till the moment of replantation, root sur- replanting permanent teeth with incomplete root develop-
face should be cleaned and the tooth should be placed in ment according to IADT [3]requires the tooth to be placed
a 2% sodium fluoride solution; aseptic treatment of the in a solution of 1mg. Clindamycin in 20 ml. the physiologi-
wound, replantation of the tooth/teeth with light pressure cal solution which gives greater chances for
and splinting with flexible splint. In the first clinical case, revascularization of the pulp. After that, the tooth should
the teeth were stored wrong, dry, in a paper napkin. The be placed in the alveolus with light pressure and should
rigid splinting that has been made leads to resorption an- be splinted to the neighbor teeth with a flexible splint for
kylosis. This means that the rigid splinting in this clinical 2 weeks.
case is a wrong clinical decision. We haven‘t obtained any Replantation of tooth 11 with incomplete root de-
information about the replantation protocol and why the velopment was made up to 60 minutes after the accident.
rigid splint was put in the treatment plan. The actual clini- It was stored in physiological solution and transported
cal protocol requires endodontic treatment 7 to 10 days af- properly. Replantation was not strictly made by instructions
ter splinting and removal of the splint 2 to 4 weeks after given by IADT [3]. The root surface has not been treated
that because the short splinting period favors the healing with Clindamycin before replantation and the tooth has not
processes in the periodontal ligamentum. In that case, the been splinted immediately after that. One hour after that
splint is taken down 2 weeks after the treatment but the the child was referred to a pediatric dentist, flexible splint
endodontic treatment has not been made on time which has been put and antibiotics have been prescribed. Con-
questions the success results of the healing process. Endo- trol radiograph has been taken and instructions for home
dontic treatment has been started 4 and a half months after care have been given to the patient and parents. In this
the accident and has been scheduled after evident case, the goal is to stimulate revascularization of the pulp
resorption in the apical region of tooth 21. Both replanted and to complete the root development under regular pro-
teeth are treated by following the protocol for treatment of fessional control.
chronical periodontitis and the aim is to reduce the root Replanted tooth was observed regularly 3 years af-
resorption of tooth 21. In the next 17 months, the resorption ter treatment. Clinical and radiograph criteria to assess
at the apical third of the root is reduced but cervical tooth condition are compared to those of the neighbor
/ J of IMAB. 2016, vol. 22, issue 4/ http://www.journal-imab-bg.org 1399
healthy tooth through the whole follow up period. The pa- of the mouth more than 60 min and has been stored in a
tient has no complaints. Tooth function and aesthetics are physiological solution [2, 3, 4]. In this case, a delayed re-
saved. The tooth is stable. All tests (visual criteria, mobil- plantation has a poor long-term prognosis. The periodon-
ity test, test for tenderness to percussion, EPT confirm pos- tal ligament will be necrotic and will not expect to heal.
sible revascularization of the pulp and completion of the The goal in doing delayed replantation of immature teeth
root development. Only the pulse oximetry test shows that in children is to maintain alveolar ridge contour. The even-
the oxygen saturation is inadequate. This is probably the tual outcome is expected to be ankylosis and resorption of
reason for the fast obliteration of the root canal as a result the root. It is important to recognize that if delayed replan-
of pulp irritation. The slight apical root resorption is prob- tation is done in a child, future treatment planning must
ably a result of the resorption processes in the periodon- take into account the occurrence of tooth ankylosis and
tium. Three years after replantation EPT and the pulse oxi- the effect of ankylosis on the alveolar ridge development.
metry test show that the pulp is still alive. Advanced ob- When ankylosis occurs, and when the infra position of the
literation of the root canal requires endodontic treatment tooth crown is more than 1 mm, it is recommended to per-
just to save the root canal and to slow down the root form decoronation to preserve the contour of the alveolar
resorption. Follow up period continues. ridge. If pulp necrosis occurs endodontic treatment should
The prognosis for the replanted tooth is good thanks be made to provide conditions for apexification by regu-
to adequate parent‘s and medical help and because of in- lar applications of calcium hydroxide for a period of time.
complete root development which gives good chances for After building up of an apical barrier root canal should be
revascularization of the pulp. Advanced obliteration of the filled up with permanent filling and the tooth should be
root canal requires endodontic treatment. The case is one finished with aesthetic restoration [3].
of the successful cases of replantation. In the presented case, there is no information for the
Presented third case is about replantation of an protocol of replantation. According to IADT [3], the proto-
avulsed permanent tooth with incomplete root develop- col requires replanted tooth to be splinted with a flexible
ment, which stayed out of the mouth no more than 60 min. splint for 4 weeks and the endodontic treatment should start
The goal for replanting still-developing (immature) teeth 7 to 10 days after the accident before taking off the splint
in children is to allow for possible revascularization of the Instead of that the splint has been removed 10 days after
pulp space [2, 3, 4]. The risk of infection-related root the accident and the endodontic treatment has not been
resorption should be weighed up against the chances of made. The patient has not been referred to a pediatric spe-
revascularization. Such resorption is very rapid in child‘s cialist for future treatment and observation. The endodon-
teeth. If revascularization does not occur, root canal treat- tic treatment has been made too late (11 months later) af-
ment may be recommended. Endodontic treatment should ter pulp necrosis and periapical abscess. Antibiotics and
provide a chance for apexification by regular application contemporary endodontic treatment stopped the progress
of calcium hydroxide till it is necessary. After building up of pathological processes. The inflammation has been lim-
of an apical barrier root canal should be filled up with per- ited and now 27 months after the accident the tooth is pre-
manent filling and the tooth should be finished with aes- served in the alveolus, there is no complaints and
thetic restoration [3]. resorption. Visually the tooth looks in a good condition,
In the presented case there were some mistakes made: the patient is still under regular observation and the long-
teeth were stored dry, they were cleaned with physiologi- term prognosis is good.
cal solution, the alveolus were irrigated with physiologi- The presented clinical case of replanted upper perma-
cal solution as well (according to IADT [3], replantation nent central incisor with developed root and the open apex
protocol requires the avulsed teeth to be soaked in a solu- is one of the best cases for long term survival of an avulsed
tion of 1 mg. Clindamycin in 20 ml physiological solu- tooth. Delayed replantation and short term splinting do not
tion for 5 min)then they were filled up withBio-Oss® spon- favor the chance for possible revascularization of the pulp.
giosa 0,25-1mm/Geistlich Biomaterials, the teeth were re- Instead of that delayed root canal treatment leads to ad-
planted with light pressure but not splinted ( the instruc- vanced periodontitis and periapical abscess. Antibiotics and
tions are flexible splint to be put for 2 weeks); the patient endodontic treatment 18 months later have successful results.
was not sent for future observation and treatment by The patient is still under regular observation because of the
pediatric dentist; endodontic treatment has been started possible resorption ankylosis.
too late after advanced resorption processes have started.
The parents showed negligent attitude about their child‘s CONCLUSION
teeth and health. The presented clinical cases show that in Bulgaria
The patient is ten and a half years old. There is a there is a lack of dental teams for complex treatment of chil-
chance the teeth to be lost because of advanced root dren with avulsed teeth. There is no good information about
resorption. Concomitant alveolar resorption will minimize recommended by IADT protocols for treating teeth which
the chance for future implant treatment. The case is an un- undergo avulsed trauma in childhood [3]. There is a lack
successful attempt for tooth replantation. The patient stays of information about how to store avulsed and found teeth
under observation by pediatric dentist and orthodontist. before replantation. This motivates us to work on a crea-
Presented forth case is about replantation of avulsed tion of an interactive guideline “Teeth traumas in child-
permanent upper incisor with open apex which stayed out hood”, which is going to be sponsored by Console of medi-
1400 http://www.journal-imab-bg.org / J of IMAB. 2016, vol. 22, issue 4/cal sciences by Medical University – Sofia, Bulgaria. Fast
and easy internet access will give a chance to promote that
necessary information about adequate steps that parents
and dentist should take in an emergency situation like
avulsion of permanent teeth during childhood.
Acknowledgement:
The article is a part of a project No 321/15. 01. 2015, sponsored by MC- Medical University- Sofia, Bulgaria to
whom we evince our acknowledgements.
The authors deny any conflicts of interest related to this study.
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Please cite this article as: Kabaktchieva R, Gateva N, Gusiyska A, Stanimirov P, Milcheva N. Dental care for children
after replantation of avulsed permanent incisors. J of IMAB. 2016 Oct-Dec;22(4):1392-1402.
DOI: https://doi.org/10.5272/jimab.2016224.1392
Received: 03/09/2016; Published online: 20/12/2016
Address for correspondence:
Professor Rossitza Kabaktchieva
Department of Pediatric Dentistry, Faculty of Dental Medicine, Medical
University - Sofia.
1, George Sofiisky Str.,1431 Sofia, Bulgaria.
E-mail: r_kabaktchieva@mail.bg
1402 http://www.journal-imab-bg.org / J of IMAB. 2016, vol. 22, issue 4/You can also read
