Complex Frontal Upper Teeth Injury with
Children – A Case Study of Preconditions for
Efficient Procedure of Such an Injury Treatment
Department for Paediatric Dentistry and Orthodontics, Gulf Medical University, UAE
Submission: April 28, 2017; Published: March 19, 2018
*Corresponding author: Dusan Surdilovic, Department for Paediatric Dentistry and Orthodontics, HOD, Gulf Medical University, Ajman, Dubai, UAE, Email: email@example.com
How to cite this article:Dusan Surdilovic. Complex Frontal Upper Teeth Injury with Children – A Case Study of Preconditions for Efficient Procedure of Such an
Injury Treatment. Adv Dent & Oral Health. 2018; 8(1): 555730. DOI: 10.19080/ADOH.2018.08.555730
Traumatic extraction of permanent teeth (Avulsion Completa) is a serious tooth injury, having an uncertain outcome and requiring a quick and proper reaction of the dentist. In this study, a full therapy plan for an 11 year old girl was shown, who came to the clinic with avulsed tooth 11, third class fracture of tooth 12 and second class fracture of tooth 21. After clinical examination and upper frontal region X-ray, replantation of tooth 11 was applied, as well as wire composite splint placement. Replantation and injured teeth endodontic treatment being successfully performed, a prosthetic sanation was done next on the patient. In the study, a clinical picture of the patient one year after the injury was also shown.
Traumatic tooth extraction (Avulsion Completa, Extrusion Completa, Exarticulation) is a rare injury of both milk and permanent teeth, but more frequently seen in the former. The most common traumatic extraction in milk teeth occurs as a result of falls, whereas in permanent teeth, the main etiological factor is direct (frontal) hitting. The most often disrupted teeth are central upper incisors. The frequency of this injury compared to others is very small, rating about 0.9% of total teeth injuries.
Traumatic tooth extraction can clinically be seen as a tooth missing from the teeth line. Diagnostically same or similar clinical picture can be seen in tooth extrusion and tooth root fracture with tooth crown loss as well, therefore an X-ray being obligatory for the final diagnosis.
Tooth replantation success depends on numerous factors: Time between traumatic extraction and replantation, the way of storing the tooth from avulsion until replantation, the level of the avulsed tooth root fracture, alveolar bone condition and prior condition of the tooth crown, pulp and periodontium, possible orthodontic irregularities and, as a very important factor, the procedure during replantation.
On July 10th 2015, a patient M.K. (born in 2004) came to the dentistry clinic with her father due to a multiple tooth injury after
a bicycle fall in which she hit directly the handlebar with her face. The girl’s father brought the avulsed tooth 11 in a cotton tissue. Almost 2 hours passed between the time when the injury occurred and her admission at the clinic. After taking the patient’s history, clinical examination and the X-ray (Figure 1), the following diagnosis was made: 11 avulsion completa dentis traumatica; 12 fracture III class dentis traumatica; fracture II class dentis traumatic; 22 contusio dentis. Tooth 11 also had II class fracture Figure 1.
Immediately after admission, tooth 11 was put into physiological solution. Decolorisation of the upper frontal region was done with 2ml of Lidokain anesthetic. Afterwards, we started wire composite splint placement on teeth 15, 14, 21, 22, 24 (Figure 2).
After the splint placement, alveoli were rinsed with coagulum physiological solution followed by a manual replantation of the traumatically avulsed tooth 11. Then, tooth 11 was bonded with the already placed wire composite splint (15, 14, 11, 21, 22 and 24) (Figure 3). The emphasis of the whole procedure is on TIME, as only 2h 7min passed from the moment of injury until replantation. After splint placement, a control X-ray was done (Figure 4). During this first visit, vital extirpation of tooth 12 pulps was done and the tooth endodontic treatment was applied with calcium hydroxide paste – Calcipupe Septodont, Cedex, France. A composite bandage was put on tooth 21. Gingival tooth 11 sulcus was rinsed with Orvagil solution (metronidazol). The patient was
given an antibiotic therapy as well (Figure 3 & 4).
24 hours after the injury, tooth 11 pulp extirpation was done,
performing endodontic treatment of tooth root canal with calcium
hydroxide paste. Tooth 21 vitality was regained on the 4th day
after the injury. Further checkups were scheduled every seven
days, during which revisions of fillings in teeth 11 and 12 were
done with the previously mentioned paste.
Prior to the splint removal, on the 21st day after the injury,
the final filling of tooth 11 was done (Endomethasone Septodent,
Cedex, France). After both final fillings, a control X-ray image was made (Figure 5). On the 28th day after the placement, the wire
composite splint was removed (Figure 6).
After splint removal, the bonded teeth in the splint were
treated with Fluorogal forte gel according to the protocol for
patients with high risk of cavity. The final composite restoration of
teeth 11 and 21 was done using restorative materials Te-Econom
Ivoclar – vivadent. Three months after the injury, one more control
X-ray image was made (Figure 7), showing regular clinical findings
with anamnesis data not showing any subjective or objective
discomfort in the patient.
Three months later, a prosthetic dental ceramic crown portion
for tooth 12 was placed. A year later, the clinical findings were
neat, with no pathological changes. Following of the patient’s
medical state is obligatory and the checks up examinations are
scheduled every three months (Figure 8 & 9).
Clinical practice shows that replantation success of avulsed
teeth is certain in 4% - 50% of cases. The main reasons for
relatively great number of unsuccessful replantation are in the
way the teeth are being treated until the replantation itself, as well
as in the period of time prior the replantation. A contribution to
this statement is the fact that success in replanting extracted and
immediately replanted teeth in laboratory conditions is 100%.
Cvek et al.  emphasize that avulsed teeth being out of alveoli
between 15 and 60 minutes, have considerably lower degree of
post replanted repsorption if they were in physiological solution
about 30 min before replantation . During the replantation
itself, it is of great importance that the cells of the tooth root suffer
as little pressure as possible, so as not to be damaged against the
alveoli wall. In that sense, it is inevitable to say that splint has
relatively bad influence due to permanent pressure of one side of
the tooth to alveoli.
During the treatment of the reported patient, we applied the
rule that it is important to replant a tooth, regardless the time
when it was brought, even if it was more than 2 hours after the
injury, because, even then, there are chances, although minimal, to
keep the tooth, and they are greater than in case of no replantation
Literature data show that there is no need to rush with
endodontic treatment of tooth root canal and filling with calcium
hydroxide, because of increased incidence of apical ankylosis as
a consequence of cytotoxic substances intrusion during canal
treatment into Periodontal Ligament area (PDL). A compromised
period of 7 to 10 days after an injury was established for
endodontic treatment in order to prevent avulsed tooth pulp
necrosis. All further delays extremely increase risk of post
replantation necrosis and tooth loss.
In the reported case we decided to do treatment according
to a specific situation – the fact that replantation was done more
than 2 hours after the injury, which also increased the risk of fast
developing necrosis processes, the fact that the patient was young
with extremely voluminized pulp chamber, which also speeds up
spreading of the inflammatory process to periodontal area (PDL).
It is also worth mentioning that storing avulsed teeth in water or
saliva should be avoided, because in these mediums PDL cells are
damaged, increasing the root resorption. Milk is a suitable media
for storing an avulsed tooth for only 15 to 20 minutes. It only
prevents cell death in short term, but it does not have the ability
to replenish them.
The period of wearing a splint is of extreme importance.
The authors agree that due to complex reparative processes in
replantation of completely disarticulated tooth, this period of
time must not be less than 3 weeks and the maximum is 6 weeks,
bearing the risk of possible post replantation complications, such
as tooth ankylose or external resorption. The patient reported
was wearing a splint for 4 weeks, what is an optimal interval for
regeneration of periodontal tissue.
It is obligatory to perform tooth replantation, regardless
the time of patient’s arrival. This is also a way for a patient to
gain confidence in the dentist who did their best for success of
the treatment. There are 3 key moments during the complete
treatment of an avulsed tooth important for the success of the
1. The time from avulsion to replantation: always do
replantation, considering that possibilities of complications
increase with longer period of time from avulsion to the
2. The moment of starting the endodontic treatment of the
tooth root canal: the case reported in this study shows that
positive results were obtained with pulp extirpation 24 hours
after avulsion, and they are related to the period of one year
after avulsion. The patient will be observed during the next
3. Prolonged time of wearing a splint: positive results in
the reported case show that optimal time for wearing a splint
in tooth avulsion is 4 weeks.