7.4
Avulsion
Nestor Cohenca
Objectives
At the end of this case, the reader should appreciate the significance of avulsion injuries and understand the immediate management and long‐term treatment involved with avulsed teeth.
Introduction
A 16‐year‐old boy presented one day after a traumatic injury in which the upper left central incisor was avulsed.
Chief Complaint
The patient reported that he was hit in the mouth with a baseball while playing catch. The patient never lost consciousness and remembers the details of the event. The upper left central incisor (UL1) was avulsed and remained dry for 30 minutes wrapped in a paper towel (Figure 7.4.1). The tooth was then placed back into the socket by his father (Figure 7.4.2), on the advice of their paediatric dentist. The patient went straight to his dentist, who confirmed the position (Figure 7.4.3) and splinted the tooth with a rigid composite resin splint (Figure 7.4.4). The patient was prescribed amoxicillin and chlorhexidine rinses and was referred to the endodontist for further management.
Medical History
The patient was fit and well.
Dental History
The patient is under regular dental care with his paediatric dentist. He completed orthodontic treatment two years ago.
Clinical Examination
Clinical examination revealed a rigid composite splint extending from the upper right lateral incisor (UR2) to the upper left canine (UL3). All maxillary and mandibular anterior teeth were examined for signs of injury. The UR1, UL1 and UL2 were tender to percussion. Only the UL1 was sensitive to palpation. All anterior maxillary teeth responded positively and within normal limits to sensibility tests (cold and electric pulp testing), except for tooth UL1 (avulsed).
What did the periapical radiographs and limited field‐of‐view cone beam computed tomography images reveal?
Two periapical radiographs and a limited field‐of‐view (FOV) cone beam computed tomography (CBCT) scan were taken and reviewed. The periapical radiographs revealed a normal periodontal ligament (PDL) space around the UL1 and UL2 (Figures 7.4.3 and 7.4.5). Further analysis of the 3D CBCT scan confirmed the correct repositioning of the replanted tooth and ruled out an alveolar bone fracture. (Figures 7.4.6 and 7.4.7). Widening of the PDL on the buccal root surface of the UL1 was noted (Figure 7.4.7). The avulsed tooth appeared to be well repositioned.
What imaging is recommended in the assessment of dental trauma?
Current guidelines advise multiple parallax, two‐dimensional periapical radiographs. The clinician should evaluate each case and determine which radiographs are appropriate, depending on the nature of the traumatic dental injuries. Diagnostic radiographs also provide a baseline for future comparisons at follow‐up examinations. The use of film holders is highly recommended to allow standardisation and reproducible radiographs.
CBCT provides enhanced visualisation of traumatic dental injuries, particularly root fractures, crown/root fractures and lateral luxations. In cases of crown/root fractures, the scan provides critical information such as the location, extent and direction of a fracture. In these specific injuries, three‐dimensional imaging is important for diagnosis and treatment planning, and should be considered, where available. A guiding principle when considering exposing a patient to ionising radiation is whether the image is likely to change the management of the injury.
Radiographic examination of avulsions should include two periapical radiographs (mesial and distal) and a CBCT scan should be considered if available. The CBCT scan may be used before and after tooth replantation to rule out alveolar bone fractures and to confirm satisfactory tooth repositioning.
Diagnosis and Treatment Planning
Diagnosis of the UL1 was prior avulsion with pulpal necrosis and symptomatic apical periodontitis.
The immediate treatment of replantation and splinting of the avulsed tooth was performed by the paediatric dentist within an hour of the trauma. Treatment recommended for the UL1 included:
- Replacement of the current rigid splint with a flexible splint (Figure 7.4.8).
- Endodontic access for pulp debridement, root canal disinfection and intracanal medication with calcium hydroxide (Figure 7.4.9).
- Splint removal at two weeks post trauma. Clinical evaluation of all anterior maxillary teeth.
- Completion of endodontic therapy three to four weeks post trauma (Figure 7.4.10).
- Follow‐up at 3 and 6 weeks followed by 3, 6, 12 and 24 months.
What type of splint should be used in traumatic dental injuries and how long should the splint remain in place?
Current protocols supports the use of a flexible splint to stabilise avulsed teeth, allowing physiological movement for better healing of the periodontium. A passive stainless steel wire of a diameter up to 0.0016 inches or 0.4 mm, or a nylon fishing line (0.13–0.25 mm) can be used and bonded to the teeth with composite resin. Splinting time varies based on the presence of alveolar fracture and the type or severity of the injury. Excessive and/or inappropriate splinting increases the likelihood of root resorption.
Treatment
Root canal treatment of the UL1 was initiated within 24 hours after the replantation and the rigid composite splint was replaced by a flexible splint. The initial endodontic therapy included pulp debridement, root canal disinfection and intracanal medication with calcium hydroxide. Three weeks later, endodontic treatment was completed using gutta percha and calcium silicate cement sealer. The coronal access was sealed with a composite restoration. The patient was followed‐up at 3, 6 and 12 months for clinical and radiographic examination (Figure 7.4.11
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